Provider Demographics
NPI:1215620877
Name:11TH ST SURGICAL LLC
Entity type:Organization
Organization Name:11TH ST SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-449-9173
Mailing Address - Street 1:1534 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4524
Mailing Address - Country:US
Mailing Address - Phone:740-355-1161
Mailing Address - Fax:
Practice Address - Street 1:1534 11TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4524
Practice Address - Country:US
Practice Address - Phone:740-355-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery