Provider Demographics
NPI:1114126596
Name:CORAL RIDGE OUTPATIENT CENTER LLC
Entity Type:Organization
Organization Name:CORAL RIDGE OUTPATIENT CENTER LLC
Other - Org Name:CORAL RIDGE OUTPATIENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:5301 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334
Mailing Address - Country:US
Mailing Address - Phone:954-832-3300
Mailing Address - Fax:954-832-3301
Practice Address - Street 1:5301 N DIXIE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3403
Practice Address - Country:US
Practice Address - Phone:954-832-3300
Practice Address - Fax:954-832-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0100X
FL1310261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty