Healthcare Provider Details

I. General information

NPI: 1043209653
Provider Name (Legal Business Name): SURGERY CENTER OF CANFIELD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4147 WESTFORD DR
CANFIELD OH
44406-8086
US

IV. Provider business mailing address

4147 WESTFORD DR
CANFIELD OH
44406-8086
US

V. Phone/Fax

Practice location:
  • Phone: 330-702-1489
  • Fax: 330-702-1545
Mailing address:
  • Phone: 330-702-1489
  • Fax: 330-702-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0734AS
License Number StateOH

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893