Healthcare Provider Details

I. General information

NPI: 1629517800
Provider Name (Legal Business Name): NORTHWEST SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13402 W COAL MINE AVE 310
LITTLETON CO
80127-5407
US

IV. Provider business mailing address

1233 N MAYFAIR RD STE 304
WAUWATOSA WI
53226-3255
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-3322
  • Fax:
Mailing address:
  • Phone: 414-257-3322
  • 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: GAIL JOYCE ODEN
Title or Position: ADMINISTRATOR
Credential: CASC. MBA
Phone: 414-257-3322