Healthcare Provider Details

I. General information

NPI: 1134053085
Provider Name (Legal Business Name): PEORIA STADIUM CREEK ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15000 N 83RD AVE, SUITE 105
PEORIA AZ
85381-2001
US

IV. Provider business mailing address

15000 N 83RD AVE, SUITE 105
PEORIA AZ
85381-2001
US

V. Phone/Fax

Practice location:
  • Phone: 623-266-1919
  • Fax: 623-321-9948
Mailing address:
  • Phone: 623-266-1919
  • Fax: 623-321-9948

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: JAY MCKIM
Title or Position: EVP CHIEF FINANCIAL OFFICER
Credential:
Phone: 949-680-3443