Basic Information
| Provider Information | |||||||||
| NPI: | 1790132322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE AMBULATORY SURGERY CENTER, LLC | ||||||||
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| OtherOrganizationName: | THE ENDOSCOPY & COLONOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15305 DALLAS PKWY | ||||||||
| Address2: | #1600 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727633893 | ||||||||
| FaxNumber: | 9726926745 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | HAZELWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630421820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143738931 | ||||||||
| FaxNumber: | 3143738935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | JENETHA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER / AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9727633893 | ||||||||
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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 |
No ID Information.