Provider Demographics
NPI:1942245725
Name:SIERRA PACIFIC SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SIERRA PACIFIC SURGERY CENTER LLC
Other - Org Name:SUMMIT SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:1630 E HERNDON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3391
Mailing Address - Country:US
Mailing Address - Phone:559-449-2888
Mailing Address - Fax:559-256-9944
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3305
Practice Address - Country:US
Practice Address - Phone:559-449-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23459ZMedicare ID - Type Unspecified