Provider Demographics
NPI:1932350238
Name:MIRAGE SURGERY CENTER
Entity Type:Organization
Organization Name:MIRAGE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-581-5575
Mailing Address - Street 1:71949 HIGHWAY 111
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4826
Mailing Address - Country:US
Mailing Address - Phone:760-568-2211
Mailing Address - Fax:
Practice Address - Street 1:71949 HIGHWAY 111
Practice Address - Street 2:SUITE 300
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4826
Practice Address - Country:US
Practice Address - Phone:760-568-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-05
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical