1598996894 NPI number — SURGICAL ELITE OF AVONDALE, LLC

Table of content: (NPI 1598996894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598996894 NPI number — SURGICAL ELITE OF AVONDALE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL ELITE OF AVONDALE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598996894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10815 W MCDOWELL RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
AVONDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85392-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-433-0110
Provider Business Mailing Address Fax Number:
623-433-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10815 W MCDOWELL RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
AVONDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-433-0110
Provider Business Practice Location Address Fax Number:
623-433-0111
Provider Enumeration Date:
08/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MORAN
Authorized Official First Name:
JENETHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3893

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  OCS4020 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com