=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043209653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGERY CENTER OF CANFIELD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2005
-----------------------------------------------------
Last Update Date | 10/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4147 WESTFORD DR
-----------------------------------------------------
City | CANFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44406-8086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-702-1489
-----------------------------------------------------
Fax | 330-702-1545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4147 WESTFORD DR
-----------------------------------------------------
City | CANFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44406-8086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-702-1489
-----------------------------------------------------
Fax | 330-702-1545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENETHA D MORAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-763-3893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 0734AS
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------