Provider Demographics
NPI:1922404441
Name:SPACE COAST SURGICAL ASSISTING LLC
Entity Type:Organization
Organization Name:SPACE COAST SURGICAL ASSISTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DANCY
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA, CST
Authorized Official - Phone:321-890-2022
Mailing Address - Street 1:1270 N WICKHAM RD STE 16-422
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8923
Mailing Address - Country:US
Mailing Address - Phone:321-890-2022
Mailing Address - Fax:
Practice Address - Street 1:749 MCDERMOTT AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3038
Practice Address - Country:US
Practice Address - Phone:321-890-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty