Healthcare Provider Details

I. General information

NPI: 1255303517
Provider Name (Legal Business Name): ST DOMINIC AMBULATORY SURGERY CENTER L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR SUITE 15
JACKSON MS
39216-4601
US

IV. Provider business mailing address

970 LAKELAND DR. SUITE 15
JAKCSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-8800
  • Fax: 601-321-8670
Mailing address:
  • Phone: 601-984-8800
  • Fax: 601-321-8670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number011
License Number StateMS

VIII. Authorized Official

Name: DR. RICHARD YELVERTON
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 601-984-8800