Provider Demographics
NPI:1962568725
Name:BRECKENRIDGE SURGERY CENTER LP
Entity type:Organization
Organization Name:BRECKENRIDGE SURGERY CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OR DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-470-5859
Mailing Address - Street 1:3201 E PRESIDENT GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3566
Mailing Address - Country:US
Mailing Address - Phone:972-470-5000
Mailing Address - Fax:972-470-5861
Practice Address - Street 1:3201 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3566
Practice Address - Country:US
Practice Address - Phone:972-470-5859
Practice Address - Fax:972-470-5861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXASC239OtherPTAN
TXHHO67AOtherBLUECROSS BLUE SHEILD
TX=========OtherTIN
TX=========OtherTIN