=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932212511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALESTINE LASER & SURGERY CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 02/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 E KOLSTAD ST
-----------------------------------------------------
City | PALESTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75801-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-723-3250
-----------------------------------------------------
Fax | 903-723-5550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501B E KOLSTAD ST
-----------------------------------------------------
City | PALESTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75801-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-723-3250
-----------------------------------------------------
Fax | 903-723-5550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | DR. DANIEL M GOLD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 903-723-3250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 007940
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------