Healthcare Provider Details

I. General information

NPI: 1235760406
Provider Name (Legal Business Name): STAR SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 N 83RD AVE STE 140
PEORIA AZ
85381-5652
US

IV. Provider business mailing address

14155 N 83RD AVE STE 140
PEORIA AZ
85381-5652
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-5842
  • Fax: 623-248-5843
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TINA MANKIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-510-3203