Provider Demographics
NPI:1982672283
Name:ROSEVILLE SURGERY CENTER, LP
Entity Type:Organization
Organization Name:ROSEVILLE SURGERY CENTER, LP
Other - Org Name:ROSEVILLE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/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 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:916-677-2488
Mailing Address - Fax:916-677-2496
Practice Address - Street 1:1420 E ROSEVILLE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3078
Practice Address - Country:US
Practice Address - Phone:916-677-2488
Practice Address - Fax:916-677-2496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000764261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMEDI-CAL 05C0001572Medicaid
CAP00366559OtherRAILROAD MEDICARE
CAZZZ05026ZMedicare PIN