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General NPI Number Information
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NPI Number | 1245128917
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Entity Type | Organization
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Legal Business Name | MIRAGE CENTER OUTPATIENT SURGERY
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Dates
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Enumeration Date | 06/24/2025
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 39935 VISTA DEL SOL STE 101
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-3211
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Country | US
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Telephone | 760-413-8182
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Fax |
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Provider Business Mailing Address
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Address Line | 39935 VISTA DEL SOL STE 206
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-3211
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Country | US
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Telephone | 760-413-8182
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Fax |
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Authorized Official
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Title or Position | ADMIN/OR SUPERVISOR
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Name | MR. JUSTYN MAWBY
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Credential |
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Telephone | 760-485-9636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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