Healthcare Provider Details

I. General information

NPI: 1063077402
Provider Name (Legal Business Name): AMBULATORY SURGICAL CENTER OF POMPTON LAKES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WANAQUE AVE
POMPTON LAKES NJ
07442-2101
US

IV. Provider business mailing address

111 WANAQUE AVE
POMPTON LAKES NJ
07442-2101
US

V. Phone/Fax

Practice location:
  • Phone: 973-225-0732
  • Fax: 973-968-6660
Mailing address:
  • Phone:
  • Fax: 973-968-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DENISE PALLIS
Title or Position: DIR OF CREDENTIALING
Credential:
Phone: 201-874-9084