Provider Demographics
NPI:1831116615
Name:EAST BAY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EAST BAY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-665-0174
Mailing Address - Street 1:505 WILLARD AVE
Mailing Address - Street 2:BUILDING 3
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2650
Mailing Address - Country:US
Mailing Address - Phone:860-665-0174
Mailing Address - Fax:860-667-2066
Practice Address - Street 1:440 SWANSEA MALL DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4114
Practice Address - Country:US
Practice Address - Phone:508-324-1171
Practice Address - Fax:508-324-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA221051Medicare ID - Type Unspecified