Provider Demographics
NPI:1407851090
Name:WICHITA FALLS ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:WICHITA FALLS ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-761-9034
Mailing Address - Street 1:1500 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4323
Mailing Address - Country:US
Mailing Address - Phone:940-761-9034
Mailing Address - Fax:
Practice Address - Street 1:1500 9TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4323
Practice Address - Country:US
Practice Address - Phone:940-761-9034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008194261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008194OtherSTATE LICENSE