Provider Demographics
NPI:1700838190
Name:WALNUT HILL SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:WALNUT HILL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-524-1001
Mailing Address - Street 1:3900 E MEXICO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3941
Mailing Address - Country:US
Mailing Address - Phone:303-800-2078
Mailing Address - Fax:303-800-2078
Practice Address - Street 1:5494 GLEN LAKES DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4308
Practice Address - Country:US
Practice Address - Phone:214-692-6220
Practice Address - Fax:214-696-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
TX008040261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165322201Medicaid
TX165322201Medicaid