MEDICARE: SPECIALTY SURGERY CENTER OF PECOS, 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

General Provider Information

NPI Number	:	1598902199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIALTY SURGERY CENTER OF PECOS, LLC

Provider Business Mailing Address
First Line	:	1569 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5277
Country	:	US
Telephone Number	:	702-370-7149
Fax Number	:

Provider Business Practice Location Address
First Line	:	1569 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5277
Country	:	US
Telephone Number	:	702-370-7149
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CRAIG FOREMAN
Credential	:	D.C., R.N.
Telephone Number	:	702-370-7149

Provider Enumeration Date	:	01/19/2009
Last Update Date	:	05/07/2009

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