Healthcare Provider Details

I. General information

NPI: 1821810326
Provider Name (Legal Business Name): VISIONARY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VISIONARY SURGERY CENTER, LLC 4335 EDISON LAKES PKWY
MISHAWAKA IN
46545
US

IV. Provider business mailing address

VISIONARY SURGERY CENTER, LLC 4335 EDISON LAKES PKWY
MISHAWAKA IN
46545
US

V. Phone/Fax

Practice location:
  • Phone: 417-447-4484
  • Fax:
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: ERIN MALLOY
Title or Position: ADMINISTRATOR
Credential:
Phone: 417-447-4484