=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174185649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PISA ASC HOLDCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2019
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4741 E CAMP LOWELL DRIVE
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-318-6035
-----------------------------------------------------
Fax | 520-795-9953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4741 E CAMP LOWELL DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-829-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OFFICER
-----------------------------------------------------
Name | GREG TURK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-333-7730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------