Provider Demographics
NPI:1205859550
Name:COMMUNITY SURGERY & LASER CENTER, LLC
Entity type:Organization
Organization Name:COMMUNITY SURGERY & LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE CYCLE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-990-7590
Mailing Address - Street 1:2 FARM COLONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-5206
Mailing Address - Country:US
Mailing Address - Phone:814-726-2303
Mailing Address - Fax:814-726-7459
Practice Address - Street 1:2 FARM COLONY DRIVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5206
Practice Address - Country:US
Practice Address - Phone:814-726-2303
Practice Address - Fax:404-305-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052930L261QA1903X
PA20821501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA154-823-4255OtherNPI-DR. GORDON WUEBBOLT
PAF34988Medicare UPIN
PA416-182-NEOMedicare ID - Type UnspecifiedDR. GORDON WUEBBOLT
PA028-914Medicare ID - Type Unspecified