Provider Demographics
NPI:1770149304
Name:BLACK RIVER AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:BLACK RIVER AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRATHER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, MBA
Authorized Official - Phone:573-331-5129
Mailing Address - Street 1:219 PHYSICIANS PARK
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-609-2444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty