Provider Demographics
NPI:1659996114
Name:LAGUNA AZUL UNLIMITED LLC
Entity Type:Organization
Organization Name:LAGUNA AZUL UNLIMITED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED SURGICAL FIRST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:817-800-1163
Mailing Address - Street 1:751 N MAIN ST APT 3318
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2773
Mailing Address - Country:US
Mailing Address - Phone:817-800-1163
Mailing Address - Fax:
Practice Address - Street 1:751 N MAIN ST APT 3318
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2773
Practice Address - Country:US
Practice Address - Phone:817-800-1163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty