MEDICARE: PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	1227	FL

General Provider Information

NPI Number	:	1619979580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	1185 DUNLAWTON AVE STE 100
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2906
Country	:	US
Telephone Number	:	386-777-7151
Fax Number	:	386-231-6545

Provider Business Practice Location Address
First Line	:	1185 DUNLAWTON AVE STE 100
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2906
Country	:	US
Telephone Number	:	386-777-7151
Fax Number	:	386-231-6545

Authorized Official
Title or Position	:	CFO
Name	:	FRANCIS OWENS
Credential	:
Telephone Number	:	606-594-0705

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	01/29/2026

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