=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942096482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT SURGICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3820 S HUALAPAI WAY STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-788-9154
-----------------------------------------------------
Fax | 702-788-9154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3820 S HUALAPAI WAY STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-803-2750
-----------------------------------------------------
Fax | 702-788-9154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | STEPHANIE HOLMSTROM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-803-2750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------