Provider Demographics
NPI:1336144617
Name:SWEETWATER SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SWEETWATER SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-382-6873
Mailing Address - Street 1:2761 COMMERCIAL WAY
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4753
Mailing Address - Country:US
Mailing Address - Phone:307-382-6873
Mailing Address - Fax:307-382-6869
Practice Address - Street 1:2761 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4753
Practice Address - Country:US
Practice Address - Phone:307-382-6873
Practice Address - Fax:307-382-6869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY05-124261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9025Medicare PIN