Healthcare Provider Details

I. General information

NPI: 1154378909
Provider Name (Legal Business Name): AMBULATORY SURGI-CENTER AT FMC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST STE B
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

PO BOX 2730
FLAGSTAFF AZ
86003-2730
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-2700
  • Fax:
Mailing address:
  • Phone: 928-214-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSC 2303
License Number StateAZ

VIII. Authorized Official

Name: SUSAN NOVAK
Title or Position: DIRECTOR
Credential:
Phone: 928-214-2700