Healthcare Provider Details

I. General information

NPI: 1104990050
Provider Name (Legal Business Name): FOUR CORNERS AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG A
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

2300 E 30TH ST BLDG A
FARMINGTON NM
87401-8991
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-2300
  • Fax: 505-564-2210
Mailing address:
  • Phone: 505-564-2300
  • Fax: 505-564-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number6701
License Number StateNM

VIII. Authorized Official

Name: MS. CHARLES REDWING
Title or Position: EXECUTIVE DIRECTOR
Credential: FACMPE
Phone: 505-564-2300