Provider Demographics
NPI:1790306991
Name:GRASS LAKE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:GRASS LAKE SURGERY CENTER LLC
Other - Org Name:GRASS LAKE SURGERY CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:EKPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-701-3100
Mailing Address - Street 1:3800 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-8961
Mailing Address - Country:US
Mailing Address - Phone:517-701-3100
Mailing Address - Fax:
Practice Address - Street 1:3800 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240
Practice Address - Country:US
Practice Address - Phone:517-701-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical