Healthcare Provider Details

I. General information

NPI: 1699332080
Provider Name (Legal Business Name): AGAVE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20045 N 19TH AVE BLDG 12
PHOENIX AZ
85027-4270
US

IV. Provider business mailing address

15333 N PIMA RD STE 305
SCOTTSDALE AZ
85260-2717
US

V. Phone/Fax

Practice location:
  • Phone: 602-313-8110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: GRANT COOK
Title or Position: MANAGER
Credential:
Phone: 602-313-8110