Provider Demographics
NPI:1639146541
Name:CENTENNIAL ASC, LLC
Entity Type:Organization
Organization Name:CENTENNIAL ASC, LLC
Other - Org Name:BAYLOR SURGICARE AT CENTENNIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:4401 COIT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0500
Mailing Address - Country:US
Mailing Address - Phone:214-619-0120
Mailing Address - Fax:214-619-0121
Practice Address - Street 1:4401 COIT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035
Practice Address - Country:US
Practice Address - Phone:214-619-0120
Practice Address - Fax:214-619-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008203261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH065AOtherBCBS OF TX
TXP00617261OtherRAILROAD MEDICARE
TXHH065AOtherBCBS OF TX