Healthcare Provider Details

I. General information

NPI: 1104874247
Provider Name (Legal Business Name): FOND DU LAC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 CAMELOT DRIVE
FOND DU LAC WI
54935
US

IV. Provider business mailing address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-5407
  • Fax:
Mailing address:
  • Phone: 920-926-4472
  • Fax: 920-926-8885

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: STEVEN N LITTLE
Title or Position: SVP & CFO
Credential:
Phone: 920-926-5402