Healthcare Provider Details

I. General information

NPI: 1013104389
Provider Name (Legal Business Name): TRACY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 W GRANT LINE RD SUITE 120
TRACY CA
95377-7330
US

IV. Provider business mailing address

2160 W GRANT LINE RD SUITE 120
TRACY CA
95377-7330
US

V. Phone/Fax

Practice location:
  • Phone: 209-836-5680
  • Fax:
Mailing address:
  • Phone:
  • 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: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5954