Healthcare Provider Details

I. General information

NPI: 1528080876
Provider Name (Legal Business Name): FRY EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CAMPUS DRIVE
GARDEN CITY KS
67846-6124
US

IV. Provider business mailing address

411 CAMPUS DRIVE
GARDEN CITY KS
67846-6124
US

V. Phone/Fax

Practice location:
  • Phone: 620-276-7699
  • Fax: 620-276-7704
Mailing address:
  • Phone: 620-276-7699
  • Fax: 620-276-7704

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 Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM S CLIFFORD
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential: M.D.
Phone: 620-275-7248