=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205894466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVIS SURGERY CENTER, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2120 COWELL BLVD SUITE 142
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95618-7840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-750-7766
-----------------------------------------------------
Fax | 530-750-7767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 BURTON HILLS BLVD. SUITE 500 ATTN: L&C
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37215-6176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-240-3820
-----------------------------------------------------
Fax | 615-234-1720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF LP
-----------------------------------------------------
Name | MR. PHILLIP A CLENDENIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-665-1283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 030001792
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------