MEDICARE: MARSHALL SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center		CA

General Provider Information

NPI Number	:	1114922549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARSHALL SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3501 PALMER DR
Second Line	:	STE 100
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-8276
Country	:	US
Telephone Number	:	530-676-6120
Fax Number	:	530-676-6130

Provider Business Practice Location Address
First Line	:	3501 PALMER DR
Second Line	:	STE 100
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-8276
Country	:	US
Telephone Number	:	530-676-6120
Fax Number	:	530-676-6130

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MARTHA PONCE-FAIR
Credential	:	RN
Telephone Number	:	530-676-6125

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/22/2020

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