Provider Demographics
NPI:1548867682
Name:DAVENPORT SURGICAL LLC
Entity type:Organization
Organization Name:DAVENPORT SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGANZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-414-4222
Mailing Address - Street 1:17838 BURKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2256
Mailing Address - Country:US
Mailing Address - Phone:402-739-8146
Mailing Address - Fax:
Practice Address - Street 1:17838 BURKE ST STE 101
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2256
Practice Address - Country:US
Practice Address - Phone:402-739-8146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical