Basic Information
| Provider Information | |||||||||
| NPI: | 1912340944 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGESTIVE HEALTH ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87388 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283047388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232477 | ||||||||
| FaxNumber: | 9103231913 | ||||||||
| Practice Location | |||||||||
| Address1: | 3202 BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232477 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | MITTIE | ||||||||
| AuthorizedOfficialMiddleName: | CANADY | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9103232477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASO123 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | ASO123 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.