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General NPI Number Information
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NPI Number | 1235372277
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Entity Type | Organization
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Legal Business Name | LAGRANGE SURGERY CENTER, LLC
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Dates
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Enumeration Date | 04/07/2009
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Last Update Date | 04/07/2009
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Provider Practice Location Address
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Address Line | 2500 VENTURA WAY
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City | LAGRANGE
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State | IN
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Zip | 46761
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Country | US
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Telephone | 574-296-6452
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Fax | 574-296-6484
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Provider Business Mailing Address
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Address Line | 500 ARCADE AVE STE 100
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City | ELKHART
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State | IN
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Zip | 46514-2478
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Country | US
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Telephone | 574-296-6452
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Fax | 574-296-6484
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR/VICE PRESIDENT
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Name | HAROON ANSARI-NAZ
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Credential | PHD
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Telephone | 517-202-7174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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