Healthcare Provider Details

I. General information

NPI: 1467060327
Provider Name (Legal Business Name): SUMMIT EYE CARE SURGERY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3073 TRENWEST DR
WINSTON SALEM NC
27103-3207
US

IV. Provider business mailing address

3073 TRENWEST DR
WINSTON SALEM NC
27103-3207
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-0960
  • Fax: 336-765-7453
Mailing address:
  • Phone: 336-765-0960
  • Fax: 336-765-7453

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 Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKAS KHEMSARA
Title or Position: CEO
Credential: MD
Phone: 336-765-0910