Healthcare Provider Details

I. General information

NPI: 1104819424
Provider Name (Legal Business Name): VALLEY AMBULATORY SURGERY CENTER, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 DEAN ST
ST CHARLES IL
60175
US

IV. Provider business mailing address

2475 DEAN ST
ST CHARLES IL
60175-4831
US

V. Phone/Fax

Practice location:
  • Phone: 630-584-9800
  • Fax: 630-584-9805
Mailing address:
  • Phone: 630-584-9800
  • Fax: 630-584-9805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7001217
License Number StateIL

VIII. Authorized Official

Name: JENNIFER B. BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5900