=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922404441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPACE COAST SURGICAL ASSISTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2014
-----------------------------------------------------
Last Update Date | 11/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 749 MCDERMOTT AVE
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-3038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-890-2022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1270 N WICKHAM RD STE 16-422
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-8923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-890-2022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | MICHAEL A DANCY
-----------------------------------------------------
Credential | CSFA, CST
-----------------------------------------------------
Telephone | 321-890-2022
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------