Healthcare Provider Details

I. General information

NPI: 1538032743
Provider Name (Legal Business Name): VALLEYGATE SURGERY CENTER OF NE PA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 3RD AVE STE D
KINGSTON PA
18704-5809
US

IV. Provider business mailing address

2028 LITHO PL
FAYETTEVILLE NC
28304-2537
US

V. Phone/Fax

Practice location:
  • Phone: 337-356-7044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ERICA KENNERSON
Title or Position: DIRECTOR OF STRATEGIC DEVELOPMENT
Credential:
Phone: 337-356-7044