Provider Demographics
NPI:1376540096
Name:DEHAVEN CATARACT SURGICAL CENTER ,INC
Entity Type:Organization
Organization Name:DEHAVEN CATARACT SURGICAL CENTER ,INC
Other - Org Name:DEHAVEN SURGICAL CENTER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL SERVICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:V
Authorized Official - Last Name:LOWNDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-7510
Mailing Address - Street 1:PO BOX 130639
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0639
Mailing Address - Country:US
Mailing Address - Phone:903-595-7510
Mailing Address - Fax:903-526-5491
Practice Address - Street 1:1424 EAST FRONT
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8501
Practice Address - Country:US
Practice Address - Phone:903-595-7510
Practice Address - Fax:903-526-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000228261Q00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085855701Medicaid
TXHH1281OtherBLUE CROSS BLUE SHIELD
TX7170358OtherAETNA
TX085855701Medicaid
TX451013Medicare PIN