MEDICARE: AKDHC SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician		AZ
2	261QA1903X	Ambulatory Surgical Clinic/Center		AZ

General Provider Information

NPI Number	:	1316464159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AKDHC SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3333 E CAMELBACK RD STE 180
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-2396
Country	:	US
Telephone Number	:	602-759-6883
Fax Number	:	602-224-3315

Provider Business Practice Location Address
First Line	:	2580 HIGHWAY 95 STE 224
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7332
Country	:	US
Telephone Number	:	928-704-7011
Fax Number	:	928-704-7014

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MISS ADONIS ESCOBEDO
Credential	:
Telephone Number	:	602-759-6883

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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