Healthcare Provider Details

I. General information

NPI: 1386277069
Provider Name (Legal Business Name): SOUTHWEST ENDOSCOPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 E BASELINE RD STE B
GILBERT AZ
85234-2336
US

IV. Provider business mailing address

2223 E BASELINE RD STE B
GILBERT AZ
85234-2336
US

V. Phone/Fax

Practice location:
  • Phone: 480-289-5266
  • Fax: 480-289-5271
Mailing address:
  • Phone: 480-289-5266
  • Fax: 480-289-5271

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: MR. ERIC BOON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 480-289-5266