Provider Demographics
NPI:1598996894
Name:SURGICAL ELITE OF AVONDALE, LLC
Entity Type:Organization
Organization Name:SURGICAL ELITE OF AVONDALE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:10815 W MCDOWELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5007
Mailing Address - Country:US
Mailing Address - Phone:623-433-0110
Mailing Address - Fax:623-433-0111
Practice Address - Street 1:10815 W MCDOWELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392
Practice Address - Country:US
Practice Address - Phone:623-433-0110
Practice Address - Fax:623-433-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOCS4020261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical