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General NPI Number Information
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NPI Number | 1588126791
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Entity Type | Organization
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Legal Business Name | WYATT SURGERY CENTER LLC
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Dates
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Enumeration Date | 04/05/2019
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 2424 N WYATT DR STE 160
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City | TUCSON
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State | AZ
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Zip | 85712-6115
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Country | US
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Telephone | 334-314-6079
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Fax |
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Provider Business Mailing Address
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Address Line | 5240 E KNIGHT DR STE 104
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City | TUCSON
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State | AZ
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Zip | 85712-2183
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Country | US
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Telephone | 520-815-5050
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL C DIESENHOUSE
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Credential | MD
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Telephone | 520-815-5050
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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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Taxonomy #2
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number |
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License Number State |
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