Provider Demographics
NPI:1154644193
Name:MIRAGE AMBULATORY SURGERY CENTER, INC
Entity Type:Organization
Organization Name:MIRAGE AMBULATORY SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KREIZENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-779-9989
Mailing Address - Street 1:39935 VISTA DEL SOL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3211
Mailing Address - Country:US
Mailing Address - Phone:760-779-9989
Mailing Address - Fax:760-779-9710
Practice Address - Street 1:39935 VISTA DEL SOL
Practice Address - Street 2:SUITE 102
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3211
Practice Address - Country:US
Practice Address - Phone:760-779-9989
Practice Address - Fax:760-779-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery