Basic Information
| Provider Information | |||||||||
| NPI: | 1497724942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK VENTURA ENDOSCOPY CENTER, LLC | ||||||||
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| OtherOrganizationName: | DIGESTIVE HEALTH CENTER OF PLANO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD # L&C | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156651283 | ||||||||
| FaxNumber: | 6152403720 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 PRESTON RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729852300 | ||||||||
| FaxNumber: | 9729852320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 007950 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | HH002A | 01 | TX | BCBSTX | OTHER | 159670201 | 05 | TX | MEDICAID |