Provider Demographics
NPI:1659373322
Name:GRAND CANYON PERFUSION, INC.
Entity Type:Organization
Organization Name:GRAND CANYON PERFUSION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-659-6964
Mailing Address - Street 1:PO BOX 27588
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-7588
Mailing Address - Country:US
Mailing Address - Phone:480-777-0607
Mailing Address - Fax:480-777-1345
Practice Address - Street 1:2753 E BROADWAY RD
Practice Address - Street 2:#101-454
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-1579
Practice Address - Country:US
Practice Address - Phone:480-659-6964
Practice Address - Fax:480-659-6791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty