Provider Demographics
NPI:1487399168
Name:WILLOW PARK ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:WILLOW PARK ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:817-415-0343
Mailing Address - Street 1:130 JIMMA DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087
Mailing Address - Country:US
Mailing Address - Phone:817-363-1410
Mailing Address - Fax:817-363-1411
Practice Address - Street 1:130 JIMMA DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087
Practice Address - Country:US
Practice Address - Phone:817-363-1410
Practice Address - Fax:817-363-1411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GI ALLIANCE SURGERY CENTER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-28
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty