Provider Demographics
NPI:1104181247
Name:ADVANCED SURGERY CENTER OF NORTHERN LOUISIANA LLC
Entity Type:Organization
Organization Name:ADVANCED SURGERY CENTER OF NORTHERN LOUISIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:318-998-5555
Mailing Address - Street 1:1601 LOUISVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6027
Mailing Address - Country:US
Mailing Address - Phone:318-998-5555
Mailing Address - Fax:
Practice Address - Street 1:1601 LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-272-2214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical