Healthcare Provider Details

I. General information

NPI: 1366756579
Provider Name (Legal Business Name): BDPEC SHOW LOW ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S WHITE MOUNTAIN RD SUITE 300
SHOW LOW AZ
85901-7111
US

IV. Provider business mailing address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-3937
  • Fax: 928-537-4729
Mailing address:
  • Phone: 602-955-1000
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DONALD G SNYDER
Title or Position: CFO
Credential:
Phone: 602-955-1000