Organization Name: | WEST LAKES SURGERY CENTER LLC |
NPI Number: | 1104933696 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | TERI S FORMANEK (PRESIDENT) |
Mailing Address: | 12499 University Ave Suite 100 Clive |
State: | IA US |
Postal Code: | 503258281 |
Phone Number: | 5159745050 |
Fax Number: | |
NPI Enumeration Date: | 08/23/2006 |
NPI Last Update Date: | 11/12/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QA1903X |
License Number: | NA |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Ambulatory Surgical |
Taxonomy Definition: |