Provider Demographics
NPI:1962466847
Name:GULF COAST ENDOSCOPY CENTER OF VENICE LLC
Entity Type:Organization
Organization Name:GULF COAST ENDOSCOPY CENTER OF VENICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:941-484-5000
Mailing Address - Street 1:1220 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7151
Mailing Address - Country:US
Mailing Address - Phone:636-938-6868
Mailing Address - Fax:636-938-1487
Practice Address - Street 1:1220 E VENICE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7151
Practice Address - Country:US
Practice Address - Phone:941-484-5000
Practice Address - Fax:941-484-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1117261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070889500Medicaid
FL070889500Medicaid
FL10C0001345Medicare Oscar/Certification
FL000F1345Medicare ID - Type Unspecified