Provider Demographics
NPI:1841068095
Name:SURGERY CENTER OF TBOPLASTICS, LLC
Entity type:Organization
Organization Name:SURGERY CENTER OF TBOPLASTICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANGELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-285-8006
Mailing Address - Street 1:1206 WESTLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2963 GULF TO BAY BLVD STE 267
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4255
Practice Address - Country:US
Practice Address - Phone:727-285-8006
Practice Address - Fax:727-216-6560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Multi-Specialty