Healthcare Provider Details

I. General information

NPI: 1861271629
Provider Name (Legal Business Name): NORTHERN LAKES SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8552 N GOVERNMENT WAY
HAYDEN ID
83835-9280
US

IV. Provider business mailing address

8552 N GOVERNMENT WAY
HAYDEN ID
83835-9280
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-4211
  • Fax: 208-773-1473
Mailing address:
  • Phone:
  • 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: WENDY THOMSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-447-3579