Provider Demographics
NPI:1811010457
Name:SOUTHEAST TEXAS BARIATRIC CENTER, LLC
Entity type:Organization
Organization Name:SOUTHEAST TEXAS BARIATRIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:ANDERUD
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, CNOR
Authorized Official - Phone:409-839-5678
Mailing Address - Street 1:3050 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1801
Mailing Address - Country:US
Mailing Address - Phone:409-832-0092
Mailing Address - Fax:409-923-1909
Practice Address - Street 1:3050 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1801
Practice Address - Country:US
Practice Address - Phone:409-832-0092
Practice Address - Fax:409-923-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical