Healthcare Provider Details

I. General information

NPI: 1871667014
Provider Name (Legal Business Name): PHOENIX SPINE GOODYEAR ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N LITCHFIELD RD SUITE 110
GOODYEAR AZ
85338-1277
US

IV. Provider business mailing address

140 N LITCHFIELD RD STE 110
GOODYEAR AZ
85338-1226
US

V. Phone/Fax

Practice location:
  • Phone: 602-256-2525
  • Fax: 602-256-0795
Mailing address:
  • Phone: 602-256-2525
  • Fax: 602-256-0795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35838
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number28519
License Number StateAZ

VIII. Authorized Official

Name: ERIC BOON
Title or Position: AO
Credential:
Phone: 480-567-0269