Basic Information
| Provider Information | |||||||||
| NPI: | 1043305840 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRINCIPAL-NEEDLES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLORADO RIVER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | NEEDLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923633103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603264531 | ||||||||
| FaxNumber: | 7603264532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | DILL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 240000227 | CA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | HSP40469K | 05 | CA | MEDICAID | HSP30469K | 05 | CA | MEDICAID | 401696 | 05 | AZ | MEDICAID |