Basic Information
| Provider Information | |||||||||
| NPI: | 1063582427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGMONT SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 W MOUNTAIN VIEW AVE | ||||||||
| Address2: | # 100 | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036820375 | ||||||||
| FaxNumber: | 3036820593 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 W MOUNTAIN VIEW AVE | ||||||||
| Address2: | # 100 | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036820375 | ||||||||
| FaxNumber: | 3036820593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | MANION | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3036820375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1112 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 04510327 | 05 | CO | MEDICAID |