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NPI Code Detail

MEDICARE: PONTCHARTRAIN LITHOTRIPSY, LLC

MEDICARE: PONTCHARTRAIN LITHOTRIPSY, 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
1261QA1903XAmbulatory Surgical Clinic/Center

General Provider Information

NPI Number : 1871771972
Entity Type Code : Organization
Provider Name (Legal Business Name) : PONTCHARTRAIN LITHOTRIPSY, LLC
Provider Business Mailing Address
First Line : 6339 E SPEEDWAY BLVD
Second Line : SUITE 201
City : TUCSON
State : AZ
Zip : 85710-1147
Country : US
Telephone Number : 520-323-8732
Fax Number : 520-258-0304
Provider Business Practice Location Address
First Line : 800 OCALA RD
Second Line : #300-346
City : TALLAHASSEE
State : FL
Zip : 32304-1669
Country : US
Telephone Number : 520-323-8732
Fax Number : 520-258-0304
Authorized Official
Title or Position : REVENUE CYCLE MANAGER OF ABS
Name : LACEY DINH
Credential :
Telephone Number : 520-258-0326
Provider Enumeration Date : 01/31/2008
Last Update Date : 12/21/2015

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Directions to “PONTCHARTRAIN LITHOTRIPSY, LLC ” Practice Location

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