Provider Demographics
NPI:1538126362
Name:WINTER HAVEN AMBULATORY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:WINTER HAVEN AMBULATORY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAISTRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-250-3640
Mailing Address - Street 1:325 AVENUE B NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4651
Mailing Address - Country:US
Mailing Address - Phone:863-291-4000
Mailing Address - Fax:863-299-9179
Practice Address - Street 1:325 AVE B NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-291-4000
Practice Address - Fax:863-299-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1063261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079234900Medicaid
FL079234900Medicaid