Healthcare Provider Details

I. General information

NPI: 1770149304
Provider Name (Legal Business Name): BLACK RIVER AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

219 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

V. Phone/Fax

Practice location:
  • Phone: 573-609-2444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID C PRATHER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA, MBA
Phone: 573-331-5129