Provider Demographics
NPI:1326527680
Name:INTRACOASTAL SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:INTRACOASTAL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:III
Authorized Official - Credentials:RN
Authorized Official - Phone:321-610-3460
Mailing Address - Street 1:2200 W EAU GALLIE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3166
Mailing Address - Country:US
Mailing Address - Phone:321-795-6095
Mailing Address - Fax:
Practice Address - Street 1:2200 W EAU GALLIE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3166
Practice Address - Country:US
Practice Address - Phone:321-795-6095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical