Provider Demographics
NPI:1912265653
Name:BRASELTON ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:BRASELTON 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:404-781-2921
Mailing Address - Street 1:PO BOX 908058
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-0912
Mailing Address - Country:US
Mailing Address - Phone:678-997-2151
Mailing Address - Fax:770-965-4056
Practice Address - Street 1:2334 SPARTA WAY STE 200
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-2001
Practice Address - Country:US
Practice Address - Phone:678-997-2151
Practice Address - Fax:770-965-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G491656Medicare PIN