Provider Demographics
NPI:1770566192
Name:SUMMERLIN BEND SURGERY CENTER LLP
Entity type:Organization
Organization Name:SUMMERLIN BEND SURGERY CENTER LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN MBA
Authorized Official - Phone:239-936-9700
Mailing Address - Street 1:5238 MASON CORBIN CT
Mailing Address - Street 2:STE 101
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7738
Mailing Address - Country:US
Mailing Address - Phone:239-936-9700
Mailing Address - Fax:239-936-9707
Practice Address - Street 1:5238 MASON CORBIN CT
Practice Address - Street 2:STE 101
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7738
Practice Address - Country:US
Practice Address - Phone:239-936-9700
Practice Address - Fax:239-936-9707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070785600Medicaid
000F1340Medicare ID - Type Unspecified