Healthcare Provider Details

I. General information

NPI: 1518873207
Provider Name (Legal Business Name): SHORT PUMP CV AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 BON SECOURS PARKWAY SUITE 100
HENRICO VA
23233
US

IV. Provider business mailing address

4140 PARKLAKE AVE STE 510
RALEIGH NC
27612-3742
US

V. Phone/Fax

Practice location:
  • Phone: 303-396-9391
  • 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 State

VIII. Authorized Official

Name: MR. CHARLES TOMLINSON KLINE IV
Title or Position: SENIOR VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 303-396-9391