Provider Demographics
NPI:1437112455
Name:SPACE COAST SURGICAL CENTER LTD
Entity Type:Organization
Organization Name:SPACE COAST SURGICAL CENTER LTD
Other - Org Name:MERRITT ISLAND SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-459-0015
Mailing Address - Street 1:220 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3490
Mailing Address - Country:US
Mailing Address - Phone:321-459-0015
Mailing Address - Fax:321-459-2291
Practice Address - Street 1:220 N SYKES CREEK PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-459-0015
Practice Address - Fax:321-459-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL984261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079154700Medicaid
FL079154700Medicaid