Provider Demographics
NPI:1437505948
Name:WATER LEAF SURGERY CENTER, LTD
Entity Type:Organization
Organization Name:WATER LEAF SURGERY CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CASC
Authorized Official - Phone:512-600-6620
Mailing Address - Street 1:5200 DAVIS LN
Mailing Address - Street 2:STE B100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1500
Mailing Address - Country:US
Mailing Address - Phone:512-834-4141
Mailing Address - Fax:512-834-4142
Practice Address - Street 1:5200 DAVIS LANE
Practice Address - Street 2:SUITE B100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749
Practice Address - Country:US
Practice Address - Phone:512-600-6620
Practice Address - Fax:512-834-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130302OtherLICENSE