Provider Demographics
NPI:1154504728
Name:TREASURE COAST SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:TREASURE COAST SURGERY CENTER, LLC
Other - Org Name:TREASURE COAST CENTER FOR SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-301-8144
Mailing Address - Street 1:1155 SE MONTEREY ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4617
Mailing Address - Country:US
Mailing Address - Phone:772-286-8028
Mailing Address - Fax:772-283-6628
Practice Address - Street 1:1155 SE MONTEREY ROAD EXT
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4617
Practice Address - Country:US
Practice Address - Phone:772-286-8028
Practice Address - Fax:772-283-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1002261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10C0001264Medicare PIN