Healthcare Provider Details

I. General information

NPI: 1164656740
Provider Name (Legal Business Name): SURGERY CENTER OF MOUNT DORA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 LAKE CENTER DR.
MOUNT DORA FL
32757
US

IV. Provider business mailing address

3710 LAKE CENTER DR.
MOUNT DORA FL
32757
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-1268
  • Fax: 352-385-3199
Mailing address:
  • Phone: 352-383-1268
  • Fax: 352-385-3199

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: MR. JUAN USON
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-383-1268