Healthcare Provider Details

I. General information

NPI: 1831200120
Provider Name (Legal Business Name): FAMILY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

IV. Provider business mailing address

1801 19TH AVE SW
WILLMAR MN
56201-4946
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-7700
  • Fax: 320-235-7701
Mailing address:
  • Phone: 320-235-7700
  • Fax: 320-235-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number330845
License Number StateMN

VIII. Authorized Official

Name: MRS. CARMEN MACIK
Title or Position: ADMINISTRATOR
Credential:
Phone: 320-214-5759