=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780167866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOMAIN SURGICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2018
-----------------------------------------------------
Last Update Date | 09/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 WOLFLIN AVE
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79109-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-350-5437
-----------------------------------------------------
Fax | 806-350-5438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2455 I 40 W
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79109-1852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-350-5437
-----------------------------------------------------
Fax | 806-350-5438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DIRECTOR
-----------------------------------------------------
Name | MS. ANGELA KATHLEEN HESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-670-5318
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------