Healthcare Provider Details

I. General information

NPI: 1457548711
Provider Name (Legal Business Name): LANDER VALLEY AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 BISHOP RANDALL DR
LANDER WY
82520-3939
US

IV. Provider business mailing address

103 POWELL CT
BRENTWOOD TN
37027-5079
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-6565
  • Fax: 307-335-6566
Mailing address:
  • Phone: 615-372-8500
  • Fax: 615-372-8572

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: DONALD J. BIVACCA
Title or Position: PRESIDENT
Credential:
Phone: 615-372-8500