=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184911257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE ASSOCIATES IN SURGICAL ASSISTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2011
-----------------------------------------------------
Last Update Date | 06/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5601 E. CAMINO DEL CELADOR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-303-4780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5601 E. CAMINO DEL CELADOR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-979-9178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JEREMY ERREN GOFTON
-----------------------------------------------------
Credential | RNFA
-----------------------------------------------------
Telephone | 520-979-9178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN139696
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------