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General NPI Number Information
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NPI Number | 1497055032
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Entity Type | Organization
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Legal Business Name | AMBULATORY SURGICAL CARE FACILITY, LLC
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Dates
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Enumeration Date | 10/29/2010
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Last Update Date | 10/29/2010
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Provider Practice Location Address
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Address Line | 1281 N FARNSWORTH AVE
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City | AURORA
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State | IL
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Zip | 60505-2445
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Country | US
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Telephone | 773-283-3131
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Fax |
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Provider Business Mailing Address
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Address Line | 4176 W MONTROSE AVE
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City | CHICAGO
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State | IL
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Zip | 60641-2161
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Country | US
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Telephone | 773-283-3131
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Fax | 773-283-0793
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Authorized Official
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Title or Position | CEO / PRESIDENT
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Name | DR. DERRICK D WALLERY
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Credential | D.C.
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Telephone | 773-283-3131
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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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