Provider Demographics
NPI:1366756579
Name:BDPEC SHOW LOW ASC LLC
Entity type:Organization
Organization Name:BDPEC SHOW LOW ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-955-1000
Mailing Address - Street 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:1500 S WHITE MOUNTAIN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7111
Practice Address - Country:US
Practice Address - Phone:928-537-3937
Practice Address - Fax:928-537-4729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTIN