Healthcare Provider Details

I. General information

NPI: 1508974353
Provider Name (Legal Business Name): SOUTHLAKE AMBULATORY SURGERY CENTER, LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7813 SPIVEY STATION BLVD SUITE 100
JONESBORO GA
30236-0000
US

IV. Provider business mailing address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

V. Phone/Fax

Practice location:
  • Phone: 770-268-6000
  • Fax: 770-268-6001
Mailing address:
  • Phone: 770-897-8000
  • Fax: 770-268-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number031127
License Number StateGA

VIII. Authorized Official

Name: MR. JOHN R MCLAIN
Title or Position: EXECUTIVE VP & COO
Credential:
Phone: 770-991-8000