1588126791 NPI number — WYATT SURGERY CENTER LLC

Table of content: (NPI 1588126791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588126791 NPI number — WYATT SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYATT SURGERY CENTER 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:
WYATT SURGERY CENTER
Provider Other Organization Name Type Code:
3
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:
1588126791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5240 E KNIGHT DR STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712-2183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-815-5050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 N WYATT DR STE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-6115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-314-6079
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DIESENHOUSE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
520-815-5050

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS0132X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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