=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891175188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX SPINE GOODYEAR ASC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2015
-----------------------------------------------------
Last Update Date | 09/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 N LITCHFIELD RD STE 110
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-533-2160
-----------------------------------------------------
Fax | 602-256-0795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 N LITCHFIELD RD STE 110
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-533-2160
-----------------------------------------------------
Fax | 602-532-7825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARKET PRESIDENT
-----------------------------------------------------
Name | ERIC BOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-567-0269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | OSC7127
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------