Provider Demographics
NPI:1205366937
Name:PROVECTUS MEDICORUM SURGICAL ASSIST, LLC
Entity Type:Organization
Organization Name:PROVECTUS MEDICORUM SURGICAL ASSIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-730-1216
Mailing Address - Street 1:PO BOX 11561
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77293-1561
Mailing Address - Country:US
Mailing Address - Phone:281-730-1216
Mailing Address - Fax:
Practice Address - Street 1:118 VINTAGE PARK BLVD STE W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4096
Practice Address - Country:US
Practice Address - Phone:281-730-1216
Practice Address - Fax:281-668-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00318246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00318OtherSTATE LICENSE