=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962455964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYPRESS SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 E 29TH ST N SUITE 100
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-634-0404
-----------------------------------------------------
Fax | 316-634-2995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26168
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73126-0168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-634-0404
-----------------------------------------------------
Fax | 316-634-2995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER AND AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENNIFER BOYD BALDOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-234-5954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | S087014
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------