Provider Demographics
NPI:1235509993
Name:PEDIATRIC AMBULATORY SURGERY CENTER SOUTHLAKE
Entity Type:Organization
Organization Name:PEDIATRIC AMBULATORY SURGERY CENTER SOUTHLAKE
Other - Org Name:CHILDRENSHEALTH SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT OF ACCOUNTING
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-456-0588
Mailing Address - Street 1:470 E STATE HIGHWAY 114
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4406
Mailing Address - Country:US
Mailing Address - Phone:817-730-5437
Mailing Address - Fax:817-724-0010
Practice Address - Street 1:470 E STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4406
Practice Address - Country:US
Practice Address - Phone:817-730-5437
Practice Address - Fax:817-724-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical