Provider Demographics
NPI:1588668503
Name:MIRAGE ENDOSCOPY CENTER, L.P.
Entity type:Organization
Organization Name:MIRAGE ENDOSCOPY CENTER, L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-837-9210
Mailing Address - Street 1:39935 VISTA DEL SOL
Mailing Address - Street 2:STE 101
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3211
Mailing Address - Country:US
Mailing Address - Phone:760-837-9210
Mailing Address - Fax:760-837-9232
Practice Address - Street 1:39935 VISTA DEL SOL
Practice Address - Street 2:STE 101
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3211
Practice Address - Country:US
Practice Address - Phone:760-837-9210
Practice Address - Fax:760-837-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000789261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01594FMedicaid
CAP00021751OtherRR
CASUR01594FMedicaid
CAAS1594OtherBC
CAZZZ25418ZMedicare ID - Type Unspecified
CASUR01594FMedicaid