Provider Demographics
NPI:1558752048
Name:INTERMOUNTAIN SURGICAL
Entity Type:Organization
Organization Name:INTERMOUNTAIN SURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RNFA
Authorized Official - Phone:951-256-8191
Mailing Address - Street 1:29396 GREEN SIDE CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5863
Mailing Address - Country:US
Mailing Address - Phone:801-580-7104
Mailing Address - Fax:951-256-8190
Practice Address - Street 1:29396 GREEN SIDE CT
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-5863
Practice Address - Country:US
Practice Address - Phone:801-580-7104
Practice Address - Fax:951-256-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA733544163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty