Healthcare Provider Details

I. General information

NPI: 1639142706
Provider Name (Legal Business Name): AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

IV. Provider business mailing address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-8373
  • Fax: 270-554-8987
Mailing address:
  • Phone: 270-554-8373
  • Fax: 270-554-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3600098
License Number StateKY

VIII. Authorized Official

Name: LAXMAIAH MANCHIKANTI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 270-554-8373