Provider Demographics
NPI:1477569069
Name:FISH POND SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:FISH POND SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-343-0832
Mailing Address - Street 1:6600 FISH POND RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2582
Mailing Address - Country:US
Mailing Address - Phone:254-751-9836
Mailing Address - Fax:254-751-9868
Practice Address - Street 1:601 W HWY 6 STE 109
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-751-9836
Practice Address - Fax:254-751-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087985001Medicaid