1386834844 NPI number — MOHAVE MEDICAL ONCOLOGY CENTER

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 1386834844 NPI number — MOHAVE MEDICAL ONCOLOGY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAVE MEDICAL ONCOLOGY CENTER
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:
1386834844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 777550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89077-7550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-471-7779
Provider Business Mailing Address Fax Number:
702-471-0484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 SANTA ROSA
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86401-2311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-471-7779
Provider Business Practice Location Address Fax Number:
702-471-0484
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KONIE
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
LINN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
702-471-7779

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  MD18958 , 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: 056037 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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