Provider Demographics
NPI:1841251501
Name:ST AUGUSTINE ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:ST AUGUSTINE ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAISTRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-250-3640
Mailing Address - Street 1:40 GROOVER LOOP STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6564
Mailing Address - Country:US
Mailing Address - Phone:904-824-6108
Mailing Address - Fax:
Practice Address - Street 1:212 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5135
Practice Address - Country:US
Practice Address - Phone:904-824-6108
Practice Address - Fax:904-823-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL812261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079055900Medicaid
FL079055900Medicaid