Provider Demographics
NPI:1346205176
Name:CORAL DESERT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:CORAL DESERT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-674-5230
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:BUILDING C
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-674-5230
Mailing Address - Fax:435-674-5231
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:BUILDING C
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-674-5230
Practice Address - Fax:435-674-5231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-ASF-52092261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00085628OtherRAILROAD MEDICARE
AZ838112Medicaid
UTP00085628OtherRAILROAD MEDICARE
UT=========001Medicaid