Healthcare Provider Details

I. General information

NPI: 1770242802
Provider Name (Legal Business Name): RENOVATION SURGICAL ASSISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10290 N 92ND ST STE 200
SCOTTSDALE AZ
85258-4528
US

IV. Provider business mailing address

4340 E INDIAN SCHOOL RD # 270
PHOENIX AZ
85018-5360
US

V. Phone/Fax

Practice location:
  • Phone: 602-767-4732
  • Fax: 602-351-5660
Mailing address:
  • Phone: 602-767-4732
  • Fax: 602-351-5660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: VANESSA KOZIOL
Title or Position: CREDENTIALING
Credential:
Phone: 480-376-6456