Provider Demographics
NPI:1477595056
Name:KISSIMMEE ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:KISSIMMEE ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANGER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:715 OAK COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4213
Mailing Address - Country:US
Mailing Address - Phone:407-931-2816
Mailing Address - Fax:407-931-3485
Practice Address - Street 1:715 OAK COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4213
Practice Address - Country:US
Practice Address - Phone:407-931-2816
Practice Address - Fax:407-931-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1130261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
283180OtherAVMED
FL6A8OtherBC/BS
AETNA HMOOther2802721
7144367OtherAETNA PPO/POS
199240OtherSTAYWELL/WELLCARE
CIGNAOther6547055
6A8OtherHEALTH OPTIONS
AMERIGROUPOther113612
199240OtherSTAYWELL/WELLCARE