Provider Demographics
NPI:1659683662
Name:PREMIER ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:PREMIER ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-573-0130
Mailing Address - Street 1:2525 W GREENWAY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4292
Mailing Address - Country:US
Mailing Address - Phone:480-573-0213
Mailing Address - Fax:
Practice Address - Street 1:2563 S VAL VISTA DR STE 101A
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6231
Practice Address - Country:US
Practice Address - Phone:480-573-0213
Practice Address - Fax:480-573-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ140976Medicare PIN