Healthcare Provider Details

I. General information

NPI: 1356463913
Provider Name (Legal Business Name): MODESTO SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E ORANGEBURG AVE STE 1
MODESTO CA
95350-5342
US

IV. Provider business mailing address

400 E ORANGEBURG AVE STE 1
MODESTO CA
95350-5342
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-3000
  • Fax: 209-526-3133
Mailing address:
  • Phone: 209-526-3000
  • Fax: 209-526-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number030000552
License Number StateCA

VIII. Authorized Official

Name: CHERYL ELAINE BONELLI
Title or Position: CORPORATE ADMINISTRATOR
Credential:
Phone: 760-685-4096