Provider Demographics
NPI:1437229135
Name:COUNTY LINE ENDOSCOPY & SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:COUNTY LINE ENDOSCOPY & SURGICAL CENTER LLC
Other - Org Name:COUNTY LINE ASC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-295-0900
Mailing Address - Street 1:9226 KENNEDY BLVD
Mailing Address - Street 2:UNIT A
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047
Mailing Address - Country:US
Mailing Address - Phone:201-295-0900
Mailing Address - Fax:201-869-9501
Practice Address - Street 1:9226 KENNEDY BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047
Practice Address - Country:US
Practice Address - Phone:201-295-0900
Practice Address - Fax:201-869-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ311175OtherHORIZON BCBS
NJ311175OtherHORIZON BCBS