Provider Demographics
NPI:1689183220
Name:CONCHO VALLEY LITHOTRIPSY, LP
Entity Type:Organization
Organization Name:CONCHO VALLEY LITHOTRIPSY, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SASSERSON
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:508-870-6565
Mailing Address - Street 1:1700 WEST PARK DR
Mailing Address - Street 2:STE 410
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-3915
Mailing Address - Country:US
Mailing Address - Phone:508-870-6565
Mailing Address - Fax:508-870-0682
Practice Address - Street 1:1700 W PARK DR STE 410
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-3915
Practice Address - Country:US
Practice Address - Phone:508-870-6565
Practice Address - Fax:508-870-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QL0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTIN