Provider Demographics
NPI:1720081664
Name:HEATON LASER AND SURGERY CENTER L L C
Entity type:Organization
Organization Name:HEATON LASER AND SURGERY CENTER L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-0444
Mailing Address - Street 1:3415 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8355
Mailing Address - Country:US
Mailing Address - Phone:903-526-0444
Mailing Address - Fax:903-526-0996
Practice Address - Street 1:3415 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8355
Practice Address - Country:US
Practice Address - Phone:903-526-0444
Practice Address - Fax:903-526-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000377261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical