Provider Demographics
NPI: | 1083991582 |
---|---|
Name: | GROGAN'S MILL SURGERY CENTER, LLC |
Entity Type: | Organization |
Organization Name: | GROGAN'S MILL SURGERY CENTER, LLC |
Other - Org Name: | CREEKSIDE SURGERY CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CINDY |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | BRODERICK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RN |
Authorized Official - Phone: | 281-292-5620 |
Mailing Address - Street 1: | 10847 KUYKENDAHL RD |
Mailing Address - Street 2: | SUITE 150 |
Mailing Address - City: | THE WOODLANDS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77382-2777 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 281-292-5620 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10847 KUYKENDAHL RD |
Practice Address - Street 2: | SUITE 150 |
Practice Address - City: | THE WOODLANDS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77382-2777 |
Practice Address - Country: | US |
Practice Address - Phone: | 281-292-5620 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-11-11 |
Last Update Date: | 2012-06-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QA1903X | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |