MEDICARE: OLIVE SURGICAL CARE, 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	:	1700137650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE SURGICAL CARE, LLC

Provider Business Mailing Address
First Line	:	8914 N 91ST AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-8390
Country	:	US
Telephone Number	:	623-877-0900
Fax Number	:	623-298-1526

Provider Business Practice Location Address
First Line	:	8914 N 91ST AVE
Second Line	:	SUITE 120
City	:	PEORIA
State	:	AZ
Zip	:	85345-8390
Country	:	US
Telephone Number	:	623-877-0900
Fax Number	:	623-298-1526

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DENA HACKWORTH
Credential	:
Telephone Number	:	623-877-0900

Provider Enumeration Date	:	10/01/2012
Last Update Date	:	10/01/2012

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Directions to “OLIVE SURGICAL CARE, LLC ” Practice Location

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