1104933696 NPI number — WEST LAKES SURGERY CENTER LLC

Table of content: (NPI 1104933696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104933696 NPI number — WEST LAKES SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST LAKES 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:
1104933696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2808 S INGRAM MILL RD
Provider Second Line Business Mailing Address:
BUILDING B
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-4042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-889-2040
Provider Business Mailing Address Fax Number:
417-889-2041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12499 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CLIVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50325-8281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-974-5050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORMANEK
Authorized Official First Name:
TERI
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
515-327-1555

Provider Taxonomy Codes

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

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

  • Identifier: 0610352 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61026 . This is a "FEDERAL EMPLOYEES HEALTH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F252394 . This is a "CARPENTERS DISTRICT COUN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F252394 . This is a "CIGNA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 61026 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F252394 . This is a "MIDLANDS AETNA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 61026 . This is a "WELLMARK HEALTH PLANS IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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