Provider Demographics
NPI:1033643747
Name:SELECT ASC DEVELOPERS OF SOUTHLAKE, LLC
Entity Type:Organization
Organization Name:SELECT ASC DEVELOPERS OF SOUTHLAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-234-4740
Mailing Address - Street 1:PO BOX 674201
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4201
Mailing Address - Country:US
Mailing Address - Phone:972-234-4740
Mailing Address - Fax:
Practice Address - Street 1:3065 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6730
Practice Address - Country:US
Practice Address - Phone:972-234-4740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical