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General NPI Number Information
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NPI Number | 1780247189
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Entity Type | Organization
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Legal Business Name | OCEANSIDE ELITE SURGICAL ASSISTING, LLC
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Dates
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Enumeration Date | 04/21/2019
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Last Update Date | 09/16/2019
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Provider Practice Location Address
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Address Line | 3319 NE 15TH CT
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-1709
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Country | US
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Telephone | 954-257-7859
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Fax | 954-616-8063
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Provider Business Mailing Address
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Address Line | 3319 NE 15TH CT
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-1709
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Country | US
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Telephone | 954-257-7859
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Fax | 954-616-8063
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHELBY ALLISON LANE
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Credential | PA-C
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Telephone | 954-257-7859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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