Provider Demographics
NPI:1013218601
Name:SOUTHLAKE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHLAKE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-328-2100
Mailing Address - Street 1:521 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6173
Mailing Address - Country:US
Mailing Address - Phone:817-328-2100
Mailing Address - Fax:817-328-2103
Practice Address - Street 1:521 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6173
Practice Address - Country:US
Practice Address - Phone:817-328-2100
Practice Address - Fax:817-328-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical