Provider Demographics
NPI:1770911463
Name:SALUBRIOUS ASC, LLC
Entity type:Organization
Organization Name:SALUBRIOUS ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-516-7880
Mailing Address - Street 1:240 HERITAGE WALK
Mailing Address - Street 2:SUITE101
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3875
Mailing Address - Country:US
Mailing Address - Phone:770-516-7880
Mailing Address - Fax:770-516-7870
Practice Address - Street 1:240 HERITAGE WALK
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3875
Practice Address - Country:US
Practice Address - Phone:770-516-7880
Practice Address - Fax:770-516-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208VP0014X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000440976ZMedicaid
GA511I720008Medicare PIN
GA000440976ZMedicaid