=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093085904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA ADVANCED ENDOSCOPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 02/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 S VAL VISTA DR SUITE 127
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-253-5656
-----------------------------------------------------
Fax | 480-253-5657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2680 S VAL VISTA DR SUITE 127
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-253-5656
-----------------------------------------------------
Fax | 480-253-5657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | ERIC BOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-679-4164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------