MEDICARE: SPRUCE SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1457073322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRUCE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	10888 FOOTHILL BLVD
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-7651
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10888 FOOTHILL BLVD
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-7651
Country	:	US
Telephone Number	:	909-463-0715
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DELLA BENNETT
Credential	:	MD
Telephone Number	:	909-463-0715

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	09/30/2024

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