Provider Demographics
NPI:1104990050
Name:FOUR CORNERS AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:FOUR CORNERS AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:REDWING
Authorized Official - Suffix:
Authorized Official - Credentials:FACMPE
Authorized Official - Phone:505-564-2300
Mailing Address - Street 1:2300 E 30TH ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8991
Mailing Address - Country:US
Mailing Address - Phone:505-564-2300
Mailing Address - Fax:505-564-2210
Practice Address - Street 1:2300 E 30TH ST BLDG A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8991
Practice Address - Country:US
Practice Address - Phone:505-564-2300
Practice Address - Fax:505-564-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6701261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS7971Medicaid
NMS7971Medicaid