Provider Demographics
NPI:1457310831
Name:CAPE CORAL FL ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:CAPE CORAL FL ENDOSCOPY ASC LLC
Other - Org Name:LIFELINE ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:665 DEL PRADO BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5630
Mailing Address - Country:US
Mailing Address - Phone:239-772-8892
Mailing Address - Fax:239-574-6262
Practice Address - Street 1:665 DEL PRADO BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5630
Practice Address - Country:US
Practice Address - Phone:239-772-8892
Practice Address - Fax:239-574-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL910261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076178800Medicaid
FL621767599OtherHUMANA MILITARY-TRICARE
FL490004452Medicare PIN
FL10-C0001128Medicare Oscar/Certification
FLF1128Medicare PIN