Healthcare Provider Details

I. General information

NPI: 1417958729
Provider Name (Legal Business Name): MENTOR SURGERY CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9485 MENTOR AVE STE 1
MENTOR OH
44060-4597
US

IV. Provider business mailing address

9485 MENTOR AVE STE 1
MENTOR OH
44060-8711
US

V. Phone/Fax

Practice location:
  • Phone: 440-205-5454
  • Fax: 440-205-5402
Mailing address:
  • Phone: 440-205-5454
  • Fax: 440-205-5402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0404AS
License Number StateOH

VIII. Authorized Official

Name: MISS TRACY ANN PETERS
Title or Position: BUSINESS OFFICE MANAGER
Credential: CPC
Phone: 440-205-5467