Provider Demographics
NPI:1457395493
Name:SPRING LAKE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SPRING LAKE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-841-4486
Mailing Address - Street 1:8711 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6813
Mailing Address - Country:US
Mailing Address - Phone:318-841-4486
Mailing Address - Fax:318-841-4489
Practice Address - Street 1:8711 LINE AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-841-4486
Practice Address - Fax:318-841-4489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017152261QA1903X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA15021Medicare PIN