Provider Demographics
NPI:1619266426
Name:ROLLA SURGICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ROLLA SURGICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MONALDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-341-2971
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0130
Mailing Address - Country:US
Mailing Address - Phone:573-341-2971
Mailing Address - Fax:573-341-8174
Practice Address - Street 1:1210 HOMELIFE PLZ
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2512
Practice Address - Country:US
Practice Address - Phone:573-341-2971
Practice Address - Fax:573-341-8174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical