Provider Demographics
NPI:1437615929
Name:BANNER ENTICARE TEMPE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:BANNER ENTICARE TEMPE SURGERY CENTER LLC
Other - Org Name:BANNER TEMPE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER-MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTAFAVI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-229-6188
Mailing Address - Street 1:2355 E CAMELBACK RD STE 700
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-9044
Mailing Address - Country:US
Mailing Address - Phone:602-550-0428
Mailing Address - Fax:
Practice Address - Street 1:1940 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7518
Practice Address - Country:US
Practice Address - Phone:480-820-7101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty