Provider Demographics
NPI:1477628725
Name:SURGERY & LASER CENTER AT PROFESSIONAL PARK LLC
Entity Type:Organization
Organization Name:SURGERY & LASER CENTER AT PROFESSIONAL PARK LLC
Other - Org Name:SURGERY & LASER CENTER AT PROFESSIONAL PARK LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-938-9836
Mailing Address - Street 1:136 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325
Mailing Address - Country:US
Mailing Address - Phone:864-938-9836
Mailing Address - Fax:864-938-9838
Practice Address - Street 1:136 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325
Practice Address - Country:US
Practice Address - Phone:864-938-9836
Practice Address - Fax:864-938-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical