Provider Demographics
NPI:1003944125
Name:VAIL VALLEY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:VAIL VALLEY SURGERY CENTER, LLC
Other - Org Name:VAIL VALLEY SURGERY CENTER VAIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEVERIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-476-8202
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-1270
Mailing Address - Country:US
Mailing Address - Phone:970-477-8200
Mailing Address - Fax:970-477-8215
Practice Address - Street 1:181 W MEADOW DR # 3R
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-476-8200
Practice Address - Fax:970-477-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0704261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67801731Medicaid
COC473498Medicare ID - Type UnspecifiedMEDICARE PROVIDER #