Healthcare Provider Details

I. General information

NPI: 1225745870
Provider Name (Legal Business Name): APOLLO SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615 E BASELINE RD STE 102
MESA AZ
85209-2000
US

IV. Provider business mailing address

7615 E BASELINE RD STE 102
MESA AZ
85209-2000
US

V. Phone/Fax

Practice location:
  • Phone: 480-597-3290
  • Fax:
Mailing address:
  • Phone: 480-597-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: FAWN BOONSTRA
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-286-7907