1720334097 NPI number — PACIFIC SURGERY CENTER, LLC

Table of content: (NPI 1720334097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720334097 NPI number — PACIFIC SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC SURGERY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720334097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6128 S LYNCREST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-334-2955
Provider Business Mailing Address Fax Number:
605-274-6186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10707 PACIFIC ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114-4762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-933-1844
Provider Business Practice Location Address Fax Number:
402-932-5891
Provider Enumeration Date:
07/24/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DESOUZA
Authorized Official First Name:
EUCLID
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
402-391-2166

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NA2347 . This is a "PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".