Healthcare Provider Details

I. General information

NPI: 1093477655
Provider Name (Legal Business Name): JLG SURGICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 E. LOWELL AVE.
GILBERT AZ
85295-6271
US

IV. Provider business mailing address

855 E. LOWELL AVE.
GILBERT AZ
85295-6271
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-6810
  • Fax: 480-834-6810
Mailing address:
  • Phone: 480-834-6810
  • Fax: 480-834-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOSE LUIS GUZMAN
Title or Position: STATUTORY AGENT
Credential: CSFA
Phone: 480-834-6810