1245343482 NPI number — PHC-LAKE HAVASU INC

Table of content: (NPI 1245343482)

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:
Provider Other Organization Name Type Code:
6
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".




Copyright © 2007-2025 www.npivalidator.com