Healthcare Provider Details

I. General information

NPI: 1487657359
Provider Name (Legal Business Name): WEST JEFFERSON SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD STE 105N
MARRERO LA
70072-3152
US

IV. Provider business mailing address

1111 MEDICAL CENTER BLVD SUITE 105 NORTH
MARRERO LA
70072
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-2332
  • Fax: 504-349-2359
Mailing address:
  • Phone: 504-349-2332
  • Fax: 504-349-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number115
License Number StateLA

VIII. Authorized Official

Name: MR. MARK JUNEAU
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 504-349-2332