Provider Demographics
NPI:1548443062
Name:GUAM SURGICENTER, LLC
Entity type:Organization
Organization Name:GUAM SURGICENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:CHE
Authorized Official - Phone:671-646-3855
Mailing Address - Street 1:633 CARLOS CAMACHO ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3127
Mailing Address - Country:US
Mailing Address - Phone:671-646-3855
Mailing Address - Fax:671-646-3854
Practice Address - Street 1:633 CARLOS CAMACHO ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3127
Practice Address - Country:US
Practice Address - Phone:671-646-3855
Practice Address - Fax:671-646-3854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUAM SURGICENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU13200100529001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty