Provider Demographics
NPI:1992983902
Name:ST CROIX GASTROENTEROLOGY CENTER LLC
Entity type:Organization
Organization Name:ST CROIX GASTROENTEROLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:340-692-1301
Mailing Address - Street 1:PO BOX 5632
Mailing Address - Street 2:
Mailing Address - City:ST CROIX
Mailing Address - State:VI
Mailing Address - Zip Code:00823-5632
Mailing Address - Country:US
Mailing Address - Phone:340-719-6300
Mailing Address - Fax:340-719-6301
Practice Address - Street 1:61 HERMAN HILL
Practice Address - Street 2:
Practice Address - City:ST CROIX
Practice Address - State:VI
Practice Address - Zip Code:00820-5720
Practice Address - Country:US
Practice Address - Phone:340-719-6300
Practice Address - Fax:340-719-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0027491Medicare PIN