Basic Information
| Provider Information | |||||||||
| NPI: | 1184601221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAY SURGERY CENTER LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1564 KINGSLEY AVENUE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
| FaxNumber: | 9042640401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1564 KINGSLEY AVENUE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
| FaxNumber: | 9042640401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | POWELL | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9042640400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1176 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.