Basic Information
| Provider Information | |||||||||
| NPI: | 1003113010 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA COAST WIDE OPEN MRI, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39 | ||||||||
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| City: | OVERGAARD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859330039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285356667 | ||||||||
| FaxNumber: | 9285355561 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 MESQUITE AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864036897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9286697480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 605261 | 05 | AZ | MEDICAID | Z146172 | 01 | AZ | MEDICARE PTAN | OTHER |