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General NPI Number Information
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NPI Number | 1437615929
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Entity Type | Organization
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Legal Business Name | BANNER ENTICARE TEMPE SURGERY CENTER LLC
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Dates
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Enumeration Date | 02/20/2019
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 1940 E SOUTHERN AVE
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City | TEMPE
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State | AZ
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Zip | 85282-7518
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Country | US
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Telephone | 480-820-7101
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Fax |
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Provider Business Mailing Address
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Address Line | 2355 E CAMELBACK RD STE 700
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City | PHOENIX
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State | AZ
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Zip | 85016-9044
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Country | US
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Telephone | 602-550-0428
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Fax |
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Authorized Official
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Title or Position | MANAGER-MEMBER
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Name | DR. HOMAN MOSTAFAVI
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Credential | DO
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Telephone | 248-229-6188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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