Basic Information
| Provider Information | |||||||||
| NPI: | 1164662912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPACE COAST SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 595 N COURTENAY PKWY STE 103 | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329534852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138901800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 595 N COURTENAY PKWY | ||||||||
| Address2: | 103 | ||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329534851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135696500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2009 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER AND AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152345954 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.