1790861243 NPI number — MOHAVE MENTAL HEALTH CLINIC INC

Table of content: (NPI 1790861243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790861243 NPI number — MOHAVE MENTAL HEALTH CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAVE MENTAL HEALTH 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:
1790861243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3707 N STOCKTON HILL RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGMAN
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86409-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-757-8111
Provider Business Mailing Address Fax Number:
928-757-3256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 MARINA BLVD
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-758-5905
Provider Business Practice Location Address Fax Number:
928-758-8790
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ABBOTT
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
928-757-8111

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  BH1474 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: OTC6117 , 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)





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