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Organization
WEST LAKES SURGERY CENTER LLC
Active
Organization
WEST LAKES SURGERY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TERI S FORMANEK M.D. (PRESIDENT)
(515) 327-1555
Entity
Organization
Contact information
Practice address
12499 UNIVERSITY AVE, SUITE 100, CLIVE, IA 50325-8281
(515) 974-5050
Mailing address
2808 S INGRAM MILL RD, BUILDING B, SPRINGFIELD, MO 65804-4042
(417) 889-2040
(417) 889-2041
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
NA
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0610352
—
IA
01
—
61026
FEDERAL EMPLOYEES HEALTH
IA
01
—
F252394
CARPENTERS DISTRICT COUN
IA
Enumeration date
08/23/2006
Last updated
06/04/2020
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