1245343482 NPI number — PHC-LAKE HAVASU INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245343482 NPI number — PHC-LAKE HAVASU INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHC-LAKE HAVASU 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:
HAVASU REGIONAL MEDICAL CENTER HOME HEALTH
Provider Other Organization Name Type Code:
3
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:
1245343482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1851 MESQUITE AVE
Provider Second Line Business Practice Location Address:
STE. 206
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-680-1209
Provider Business Practice Location Address Fax Number:
928-680-7914
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GIOVANETTI
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-920-7000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA0063 , 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: 435992 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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