1295880722 NPI number — MOHAVE PULMONARY AND SLEEP DISORDER CLINIC, INC

Table of content: (NPI 1295880722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295880722 NPI number — MOHAVE PULMONARY AND SLEEP DISORDER CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAVE PULMONARY AND SLEEP DISORDER CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295880722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLHEAD CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86439-0245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-758-2002
Provider Business Mailing Address Fax Number:
928-758-1884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2771 SILVER CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BULLHEAD CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86442-7959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-758-2002
Provider Business Practice Location Address Fax Number:
928-758-1884
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AHMED
Authorized Official First Name:
MAQBOOL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-758-2002

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25051 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AZ0722040 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 421488 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: XPY202551 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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