Provider Demographics
NPI:1356463913
Name:MODESTO SURGERY CENTER LLC
Entity Type:Organization
Organization Name:MODESTO SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-685-4096
Mailing Address - Street 1:400 E ORANGEBURG AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5342
Mailing Address - Country:US
Mailing Address - Phone:209-526-3000
Mailing Address - Fax:209-526-3133
Practice Address - Street 1:400 E ORANGEBURG AVE STE 1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5342
Practice Address - Country:US
Practice Address - Phone:209-526-3000
Practice Address - Fax:209-526-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000552261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01324FMedicaid
CASUR01324FMedicaid
CA=========OtherFEDERAL TAX ID
CAZZZ00728ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID