Healthcare Provider Details

I. General information

NPI: 1144206665
Provider Name (Legal Business Name): MOBERLY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 SILVA LN
MOBERLY MO
65270-3660
US

IV. Provider business mailing address

2103 SILVA LN
MOBERLY MO
65270-3660
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-1266
  • Fax: 660-263-8377
Mailing address:
  • Phone: 660-263-1266
  • Fax: 660-263-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number164-0
License Number StateMO

VIII. Authorized Official

Name: MRS. MARTHA WOOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 660-263-1266