MEDICARE: EAST VALLEY SURGICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1174183636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY SURGICAL CENTER

Provider Business Mailing Address
First Line	:	1984 E BASELINE RD
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1535
Country	:	US
Telephone Number	:	480-930-4018
Fax Number	:

Provider Business Practice Location Address
First Line	:	1984 E BASELINE RD
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1535
Country	:	US
Telephone Number	:	480-930-4018
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	SHAWN VIGNEAU
Credential	:	DC
Telephone Number	:	480-930-4018

Provider Enumeration Date	:	06/17/2019
Last Update Date	:	06/17/2019

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Directions to “EAST VALLEY SURGICAL CENTER ” Practice Location

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