Provider Demographics
NPI:1811947062
Name:WACO GASTROENTEROLOGY ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:WACO GASTROENTEROLOGY ENDOSCOPY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:
Practice Address - Street 1:364 RICHLAND WEST CIR
Practice Address - Street 2:SUITE B
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7919
Practice Address - Country:US
Practice Address - Phone:615-665-1283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7983261QE0800X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
45-C0001337Medicare ID - Type Unspecified
TXASC185Medicare PIN