Healthcare Provider Details

I. General information

NPI: 1245128917
Provider Name (Legal Business Name): MIRAGE CENTER OUTPATIENT SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39935 VISTA DEL SOL STE 101
RANCHO MIRAGE CA
92270-3211
US

IV. Provider business mailing address

39935 VISTA DEL SOL STE 206
RANCHO MIRAGE CA
92270-3211
US

V. Phone/Fax

Practice location:
  • Phone: 760-413-8182
  • Fax:
Mailing address:
  • Phone: 760-413-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTYN MAWBY
Title or Position: ADMIN/OR SUPERVISOR
Credential:
Phone: 760-485-9636