Healthcare Provider Details

I. General information

NPI: 1134947328
Provider Name (Legal Business Name): COFFEE ROAD SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 COFFEE RD
MODESTO CA
95355-3188
US

IV. Provider business mailing address

1335 COFFEE RD
MODESTO CA
95355-3188
US

V. Phone/Fax

Practice location:
  • Phone: 209-492-0483
  • Fax:
Mailing address:
  • Phone: 209-492-0483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC BOON
Title or Position: OFFICER/AO
Credential:
Phone: 480-567-0269