| Organization Name: | BRASELTON ENDOSCOPY CENTER, LLC |
| NPI Number: | 1912265653 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SCOTT A CLARK (MANAGING PARTNER) |
| Mailing Address: | 1515 River Pl Suite 320 Braselton |
| State: | GA US |
| Postal Code: | 305175602 |
| Phone Number: | 7705368109 |
| Fax Number: | 7705363203 |
| NPI Enumeration Date: | 05/01/2012 |
| NPI Last Update Date: | 01/07/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QE0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Endoscopy |
| Taxonomy Definition: | |