Provider Demographics
NPI:1013021682
Name:PHOENIX EYE SURGICAL CENTER PLC
Entity Type:Organization
Organization Name:PHOENIX EYE SURGICAL CENTER PLC
Other - Org Name:CENTRAL PHOENIX SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-279-0044
Mailing Address - Street 1:5133 N CENTRAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1438
Mailing Address - Country:US
Mailing Address - Phone:602-279-0044
Mailing Address - Fax:602-279-0088
Practice Address - Street 1:5133 N CENTRAL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1438
Practice Address - Country:US
Practice Address - Phone:602-279-0044
Practice Address - Fax:602-279-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ22913Medicare ID - Type Unspecified