Basic Information
| Provider Information | |||||||||
| NPI: | 1033589742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SELECT AMBULATORY SURGERY CENTER OF FT WORTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674394 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 COOPER ST | ||||||||
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| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCGILL | ||||||||
| AuthorizedOfficialFirstName: | KRISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF NETWORK DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 9722157410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 130265 | 01 | TX | LICENSE | OTHER |