Provider Demographics
NPI:1215204268
Name:PROVINCIAL PARK SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:PROVINCIAL PARK SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:MENNEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:GALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-646-1114
Mailing Address - Street 1:21300 PROVINCIAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7580
Mailing Address - Country:US
Mailing Address - Phone:713-554-7500
Mailing Address - Fax:713-554-6656
Practice Address - Street 1:21300 PROVINCIAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:713-554-7500
Practice Address - Fax:713-554-6656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical