Basic Information
| Provider Information | |||||||||
| NPI: | 1538126362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTER HAVEN AMBULATORY SURGICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 AVENUE B NW | ||||||||
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| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632914000 | ||||||||
| FaxNumber: | 8632999179 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 AVE B NW | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632914000 | ||||||||
| FaxNumber: | 8632999179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEMAISTRE | ||||||||
| AuthorizedOfficialFirstName: | COLLIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4692503640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1063 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 079234900 | 05 | FL | MEDICAID |