Provider Demographics
NPI:1609269232
Name:SURGICAL CENTER OF PONTE VEDRA BEACH LLC
Entity Type:Organization
Organization Name:SURGICAL CENTER OF PONTE VEDRA BEACH LLC
Other - Org Name:PONTE VEDRA BEACH SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-285-1199
Mailing Address - Street 1:1030 A1A N
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4019
Mailing Address - Country:US
Mailing Address - Phone:907-285-1199
Mailing Address - Fax:907-285-1197
Practice Address - Street 1:1030 A1A N
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4019
Practice Address - Country:US
Practice Address - Phone:907-285-1199
Practice Address - Fax:907-285-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-06
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1215261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical