Basic Information
| Provider Information | |||||||||
| NPI: | 1629386784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODESSA ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 COMMERCE ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153456900 | ||||||||
| FaxNumber: | 6156917214 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323358300 | ||||||||
| FaxNumber: | 4323358330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOLST | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, BOARD OF MANAGERS | ||||||||
| AuthorizedOfficialTelephone: | 6153456900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 007948 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.