Provider Demographics
NPI:1639142706
Name:AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:AMBULATORY SURGERY CENTER LLC
Other - Org Name:AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAXMAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-554-8373
Mailing Address - Street 1:2831 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8041
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:2831 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8041
Practice Address - Country:US
Practice Address - Phone:270-554-8373
Practice Address - Fax:270-554-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3600098261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36000909Medicaid
KY36000909Medicaid
IL=========001Medicaid
KY490005177Medicare PIN