Provider Demographics
NPI:1407202484
Name:SPORTSORTHO SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SPORTSORTHO SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDBOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-465-1091
Mailing Address - Street 1:PO BOX 531060
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78553-1060
Mailing Address - Country:US
Mailing Address - Phone:956-232-3088
Mailing Address - Fax:956-232-3077
Practice Address - Street 1:610 KAIMALI DR
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-0233
Practice Address - Country:US
Practice Address - Phone:956-371-2243
Practice Address - Fax:855-594-8131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX391353501Medicaid
TX45D2145076OtherCLIA ID NUMBER
TX130384OtherSTATE LICENSE