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General NPI Number Information
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NPI Number | 1760414056
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Entity Type | Organization
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Legal Business Name | VAN DYCK ASC, LLC
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 02/17/2022
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Provider Practice Location Address
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Address Line | 1024 KELLEY DR
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City | PARIS
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State | TN
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Zip | 38242-4500
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Country | US
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Telephone | 731-642-5003
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Fax | 731-642-8756
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Provider Business Mailing Address
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Address Line | 1024 KELLEY DR
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City | PARIS
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State | TN
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Zip | 38242-4500
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Country | US
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Telephone | 731-642-5003
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Fax | 731-642-8756
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | JAMES C LODEN
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Credential | M.D.
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Telephone | 731-642-5003
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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 | 0000000023
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | TN23
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License Number State | TN
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