Provider Demographics
NPI:1699469593
Name:SOUL SURGERY WILSON SMITH CENTER LLC
Entity type:Organization
Organization Name:SOUL SURGERY WILSON SMITH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-912-3105
Mailing Address - Street 1:PO BOX 12434
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-2434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12816 E TURQUOISE AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5300
Practice Address - Country:US
Practice Address - Phone:480-912-3105
Practice Address - Fax:480-477-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility