Provider Demographics
NPI:1285202077
Name:SURGCENTER OF PINE RIDGE LLC
Entity Type:Organization
Organization Name:SURGCENTER OF PINE RIDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-478-0051
Mailing Address - Street 1:12871 TRADE WAY DR
Mailing Address - Street 2:STE 12
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7334
Mailing Address - Country:US
Mailing Address - Phone:239-478-0051
Mailing Address - Fax:
Practice Address - Street 1:12871 TRADE WAY DR
Practice Address - Street 2:STE 12
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7334
Practice Address - Country:US
Practice Address - Phone:239-478-0051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical