Provider Demographics
NPI:1770242802
Name:RENOVATION SURGICAL ASSISTS, LLC
Entity type:Organization
Organization Name:RENOVATION SURGICAL ASSISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZIOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-376-6456
Mailing Address - Street 1:4340 E INDIAN SCHOOL RD # 270
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5360
Mailing Address - Country:US
Mailing Address - Phone:602-767-4732
Mailing Address - Fax:602-351-5660
Practice Address - Street 1:10290 N 92ND ST STE 200
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4528
Practice Address - Country:US
Practice Address - Phone:602-767-4732
Practice Address - Fax:602-351-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid