Provider Demographics
NPI:1790132322
Name:RIVERSIDE AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:RIVERSIDE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:THE ENDOSCOPY & COLONOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
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 1:15305 DALLAS PKWY
Mailing Address - Street 2:#1600
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4637
Mailing Address - Country:US
Mailing Address - Phone:972-763-3893
Mailing Address - Fax:972-692-6745
Practice Address - Street 1:100 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1820
Practice Address - Country:US
Practice Address - Phone:314-373-8931
Practice Address - Fax:314-373-8935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical