Provider Demographics
NPI:1063582427
Name:LONGMONT SURGERY CENTER, LLC
Entity type:Organization
Organization Name:LONGMONT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-682-0375
Mailing Address - Street 1:2030 W MOUNTAIN VIEW AVE
Mailing Address - Street 2:# 100
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-682-0375
Mailing Address - Fax:303-682-0593
Practice Address - Street 1:2030 W MOUNTAIN VIEW AVE
Practice Address - Street 2:# 100
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-682-0375
Practice Address - Fax:303-682-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1112261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04510327Medicaid
CO04510327Medicaid