Healthcare Provider Details

I. General information

NPI: 1487716650
Provider Name (Legal Business Name): CARONDELET ST. MARY'S NORTHWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W ORANGE GROVE RD
TUCSON AZ
85741-3117
US

IV. Provider business mailing address

2220 W ORANGE GROVE RD
TUCSON AZ
85741-3117
US

V. Phone/Fax

Practice location:
  • Phone: 520-877-5660
  • Fax: 520-877-5669
Mailing address:
  • Phone: 520-877-5660
  • Fax: 520-877-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSC3857
License Number StateAZ

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: OFFICER / AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893