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General NPI Number Information
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NPI Number | 1477178879
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Entity Type | Organization
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Legal Business Name | SURGCENTER OF FAYETTEVILLE, LLC
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Dates
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Enumeration Date | 06/11/2020
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 1905 E MISSION BLVD STE 5
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-3129
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Country | US
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Telephone | 501-554-1273
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Fax |
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Provider Business Mailing Address
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Address Line | 1905 E MISSION BLVD STE 5
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-3129
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Country | US
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Telephone | 501-554-1273
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Fax |
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Authorized Official
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Title or Position | ADMINSITRATOR
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Name | KELLI YOUNG
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Credential | RN
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Telephone | 501-554-1273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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