Provider Demographics
NPI:1831116698
Name:LASER AND OUTPATIENT SURGERY CENTER LLC
Entity type:Organization
Organization Name:LASER AND OUTPATIENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:6925 NW 11TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-3101
Mailing Address - Country:US
Mailing Address - Phone:352-331-1590
Mailing Address - Fax:
Practice Address - Street 1:6925 NW 11TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-3101
Practice Address - Country:US
Practice Address - Phone:352-331-1590
Practice Address - Fax:352-331-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1253261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00346824OtherRR MEDICARE
FL076650000Medicaid