MEDICARE: PREMIER ENDOSCOPY CENTER, LLC

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	:	1659683662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER ENDOSCOPY CENTER, LLC

Provider Business Mailing Address
First Line	:	2525 W GREENWAY RD STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-4292
Country	:	US
Telephone Number	:	480-573-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	2563 S VAL VISTA DR STE 101A
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-6231
Country	:	US
Telephone Number	:	480-573-0213
Fax Number	:	480-573-0214

Authorized Official
Title or Position	:	DO, OWNER
Name	:	JARRETT LEATHEM
Credential	:
Telephone Number	:	480-573-0130

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	06/28/2022

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