Healthcare Provider Details

I. General information

NPI: 1073107850
Provider Name (Legal Business Name): RIVIERA SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 AZ-95 #63
BULLHEAD CITY AZ
86442
US

IV. Provider business mailing address

3003 AZ-95 #63
BULLHEAD CITY AZ
86442
US

V. Phone/Fax

Practice location:
  • Phone: 909-994-5105
  • Fax:
Mailing address:
  • Phone: 928-483-4566
  • Fax: 928-483-4566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK DIEP
Title or Position: ADMINISTRATOR
Credential:
Phone: 928-505-7246