Provider Demographics
NPI:1750456539
Name:WIREGRASS RANCH ASC HOLDINGS LLC
Entity type:Organization
Organization Name:WIREGRASS RANCH ASC HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF AMBULATORY SURGERY CENTERS
Authorized Official - Prefix:
Authorized Official - First Name:GAURAV
Authorized Official - Middle Name:
Authorized Official - Last Name:SOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-841-8346
Mailing Address - Street 1:14547 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2709
Mailing Address - Country:US
Mailing Address - Phone:813-979-0440
Mailing Address - Fax:813-615-0296
Practice Address - Street 1:14547 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2709
Practice Address - Country:US
Practice Address - Phone:813-978-1494
Practice Address - Fax:813-615-0296
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WIREGRASS RANCH ASC HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1189261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1189OtherLICENSE #
FL1189OtherLICENSE #
FL075623700Medicaid
FL075623700Medicaid