Provider Demographics
NPI:1710012869
Name:SHADELANDS SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SHADELANDS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:TRUE
Authorized Official - Last Name:PRESCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-933-7100
Mailing Address - Street 1:100 N WIGET LN
Mailing Address - Street 2:SUITE #110
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-5988
Mailing Address - Country:US
Mailing Address - Phone:925-933-7100
Mailing Address - Fax:
Practice Address - Street 1:100 N WIGET LN
Practice Address - Street 2:SUITE #110
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-5988
Practice Address - Country:US
Practice Address - Phone:925-933-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05187ZMedicare PIN