Healthcare Provider Details

I. General information

NPI: 1689761546
Provider Name (Legal Business Name): GATEWAY AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 NORTHEAST GATEWAY COURT, NE
CONCORD NC
28025
US

IV. Provider business mailing address

1025 NORTHEAST GATEWAY COURT, NE
CONCORD NC
28025
US

V. Phone/Fax

Practice location:
  • Phone: 704-920-7020
  • Fax: 704-920-7063
Mailing address:
  • Phone: 704-920-7020
  • Fax: 704-920-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberAS0070
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number060202
License Number StateNC

VIII. Authorized Official

Name: ROBERT BASHORE
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-920-7027