Provider Demographics
NPI:1740798685
Name:BON SECOURS AMBULATORY SERVICES LLC
Entity type:Organization
Organization Name:BON SECOURS AMBULATORY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CORPORATE RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:7229 FOREST AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3765
Mailing Address - Country:US
Mailing Address - Phone:804-281-0275
Mailing Address - Fax:804-521-9344
Practice Address - Street 1:1501 MAPLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:804-285-2300
Practice Address - Fax:804-527-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD347OtherMEDICARE PTAN