Provider Demographics
NPI:1790430072
Name:360 SURGICAL ASSISTING OF CENTRAL TEXAS,LLC
Entity Type:Organization
Organization Name:360 SURGICAL ASSISTING OF CENTRAL TEXAS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED SURGICAL FIRST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERIBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-644-1931
Mailing Address - Street 1:2950 E OLD SETTLERS BLVD UNIT 30
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2478
Mailing Address - Country:US
Mailing Address - Phone:512-644-1931
Mailing Address - Fax:
Practice Address - Street 1:901 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6903
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty