Provider Demographics
NPI:1619979580
Name:PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PORT ORANGE ENDOSCOPY & SURGERY CENTER LLC
Other - Org Name:ADVENTHEALTH SURGERY CENTER PORT ORANGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASC ADMINISTRATOR, NURSING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:386-777-7151
Mailing Address - Street 1:1185 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2905
Mailing Address - Country:US
Mailing Address - Phone:386-777-7151
Mailing Address - Fax:
Practice Address - Street 1:1185 DUNLAWTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2906
Practice Address - Country:US
Practice Address - Phone:386-672-0017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1227261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1449Medicare PIN