Provider Demographics
NPI:1043303894
Name:DOCTORS OUTPATIENT SURGERY CENTER OF JUPITER, LLC
Entity Type:Organization
Organization Name:DOCTORS OUTPATIENT SURGERY CENTER OF JUPITER, LLC
Other - Org Name:LASER & SURGERY CENTER OF THE PALM BEACHES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:3602 KYOTO GARDENS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:561-799-3388
Mailing Address - Fax:561-799-3389
Practice Address - Street 1:3602 KYOTO GARDENS DRIVE
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-799-3388
Practice Address - Fax:561-799-3389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1172261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070793700Medicaid
FLF1332Medicare PIN