Healthcare Provider Details

I. General information

NPI: 1992706840
Provider Name (Legal Business Name): AMBULATORY SURGERY CENTER OF BURLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 HILAND AVE SUITE E
BURLEY ID
83318-1564
US

IV. Provider business mailing address

1344 HILAND AVE SUITE E
BURLEY ID
83318-1564
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-8888
  • Fax: 208-678-5833
Mailing address:
  • Phone: 208-677-8888
  • Fax: 208-675-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH R. PETERSEN
Title or Position: CEO
Credential: M.D.
Phone: 208-677-8888