Provider Demographics
NPI:1972850808
Name:LAKE RIDGE AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:LAKE RIDGE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:LAKE RIDGE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:703-357-9568
Mailing Address - Street 1:12825 MINNIEVILLE ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-357-9568
Mailing Address - Fax:703-357-9575
Practice Address - Street 1:12825 MINNIEVILLE ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-357-9568
Practice Address - Fax:703-357-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ409820001Medicare PIN