Healthcare Provider Details

I. General information

NPI: 1689755928
Provider Name (Legal Business Name): CANYON AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/12/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6036 N 19TH AVE SUITE 100
PHOENIX AZ
85015-2106
US

IV. Provider business mailing address

6036 N 19TH AVE SUITE 100
PHOENIX AZ
85015-2106
US

V. Phone/Fax

Practice location:
  • Phone: 602-589-8000
  • Fax: 602-249-8084
Mailing address:
  • Phone: 602-589-8000
  • Fax: 602-249-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSC2285
License Number StateAZ

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIALS
Credential:
Phone: 615-234-5954