Healthcare Provider Details

I. General information

NPI: 1780103507
Provider Name (Legal Business Name): AMBULATORY SURGERY CENTER OF BURLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 HILAND AVE STE E
BURLEY ID
83318-1564
US

IV. Provider business mailing address

1344 HILAND AVE STE 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: 208-678-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH R PETERSEN
Title or Position: CEO
Credential: MD
Phone: 208-677-8888