MEDICARE: DIGESTIVE HEALTH ENDOSCOPY 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	ASO123	NC
2	261QE0800X	Endoscopy Clinic/Center	ASO123	NC

General Provider Information

NPI Number	:	1912340944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGESTIVE HEALTH ENDOSCOPY CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 87388
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-7388
Country	:	US
Telephone Number	:	910-323-2477
Fax Number	:	910-323-1913

Provider Business Practice Location Address
First Line	:	3202 BOONE TRL
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28306
Country	:	US
Telephone Number	:	910-323-2477
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	MITTIE CANADY ELLIOTT
Credential	:
Telephone Number	:	910-323-2477

Provider Enumeration Date	:	04/09/2013
Last Update Date	:	05/30/2018

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