Healthcare Provider Details

I. General information

NPI: 1992713176
Provider Name (Legal Business Name): DESERT RIDGE OUTPATIENT SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE 100
PHOENIX AZ
85050
US

IV. Provider business mailing address

20940 N TATUM BLVD STE 100
PHOENIX AZ
85050-4265
US

V. Phone/Fax

Practice location:
  • Phone: 480-502-4000
  • Fax: 480-502-4050
Mailing address:
  • Phone: 480-502-4000
  • Fax: 480-502-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSC4133
License Number StateAZ

VIII. Authorized Official

Name: ERIC BOON
Title or Position: OFFICER / AUTHORIZED OFFICIAL
Credential:
Phone: 480-567-0269