Provider Demographics
NPI:1063517316
Name:TEXOMA OUTPATIENT SURGERY CENTER, INC.
Entity type:Organization
Organization Name:TEXOMA OUTPATIENT SURGERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-723-2499
Mailing Address - Street 1:1712 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5020
Mailing Address - Country:US
Mailing Address - Phone:940-723-2499
Mailing Address - Fax:940-723-2497
Practice Address - Street 1:1712 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5020
Practice Address - Country:US
Practice Address - Phone:940-723-2499
Practice Address - Fax:940-723-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX317367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C10NOtherBCBS
TX00C10NOtherBCBS