Healthcare Provider Details

I. General information

NPI: 1265487474
Provider Name (Legal Business Name): HORSESHOE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 GOLF COURSE RD SUITE 105
GRAND RAPIDS MN
55744-9603
US

IV. Provider business mailing address

1542 GOLF COURSE RD SUITE 105
GRAND RAPIDS MN
55744-9603
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0667
  • Fax: 218-326-3435
Mailing address:
  • Phone: 218-326-0667
  • Fax: 218-326-3435

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: KELLY SKELLY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 218-326-3937