Provider Demographics
NPI:1093086183
Name:CHANDLER ENDOSCOPY AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:CHANDLER ENDOSCOPY AMBULATORY SURGERY CENTER, LLC
Other - Org Name:CHANDLER ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:2095 W PECOS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5724
Mailing Address - Country:US
Mailing Address - Phone:480-292-9795
Mailing Address - Fax:480-292-9818
Practice Address - Street 1:2095 W PECOS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5724
Practice Address - Country:US
Practice Address - Phone:480-292-9795
Practice Address - Fax:480-292-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC514261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ153605Medicare PIN
AZ03C0001279Medicare Oscar/Certification