Provider Demographics
NPI:1376709907
Name:ARDMORE REGIONAL SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ARDMORE REGIONAL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:580-224-0007
Mailing Address - Street 1:2002 12TH AVE NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1227
Mailing Address - Country:US
Mailing Address - Phone:580-224-0007
Mailing Address - Fax:
Practice Address - Street 1:2002 12TH AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1227
Practice Address - Country:US
Practice Address - Phone:580-224-0007
Practice Address - Fax:580-223-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0064261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical