MEDICARE: TRAILS EDGE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639650161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAILS EDGE SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	28930 TRAILS EDGE BLVD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7582
Country	:	US
Telephone Number	:	239-333-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	28930 TRAILS EDGE BLVD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7582
Country	:	US
Telephone Number	:	239-333-3200
Fax Number	:

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	JACKY LUCIA
Credential	:
Telephone Number	:	239-963-7365

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/23/2018

Similar Medicare Providers

1659711018 — 21ST CENTURY ONCOLOGY LLC
Practice Location Address:

28930 TRAILS EDGE BLVD
BONITA SPRINGS, FL
34134-7582

Practice Phone: 239-495-3000
Practice Fax: 239-948-5375

1306209200 — GULFSHORE UROLOGY LLC
Practice Location Address:

28930 TRAILS EDGE BLVD , SUITE 200
BONITA SPRINGS, FL
34134-7582

Practice Phone: 239-333-3200
Practice Fax: 239-992-5785

1740134493 — RYAN SHOWALTER
Practice Location Address:

8540 SCARBOROUGH DR STE 350
COLORADO SPRINGS, CO
80920-7582

Practice Phone: 817-964-2211
Practice Fax:

1871837138 — JASON LYNN WILKINSON DPT
Practice Location Address:

8540 SCARBOROUGH DR STE 350
COLORADO SPRINGS, CO
80920-7582

Practice Phone: 719-590-7777
Practice Fax:

1437157724 — GUILLERMO BOHM MD
Practice Location Address:

4061 BONITA BEACH RD STE 101
BONITA SPRINGS, FL
34134-4073

Practice Phone: 239-301-0105
Practice Fax: 239-301-0110

1336147636 — RONICA M KLUGE MD
Practice Location Address:

24600 S TAMIAMI TRL , SUITE 400
BONITA SPRINGS, FL
34134-7022

Practice Phone: 239-948-3761
Practice Fax: 239-931-3454

Directions to “TRAILS EDGE SURGERY CENTER, LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.