Provider Demographics
NPI:1114781556
Name:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ASCS
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUVALDT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:817-893-2381
Mailing Address - Street 1:550 RESERVE ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1604
Mailing Address - Country:US
Mailing Address - Phone:817-893-2381
Mailing Address - Fax:
Practice Address - Street 1:3882 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTROINTESTINAL ASSOCIATES ENDOSCOPY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy