=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619370434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDPOINT SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1327 SUPERIOR ST SUITE 111
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-501-8895
-----------------------------------------------------
Fax | 208-965-8128
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1327 SUPERIOR ST SUITE 111
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-501-8895
-----------------------------------------------------
Fax | 208-965-8128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | JEFFREY S ISPIRESCU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-263-9757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | W137644
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------