Basic Information
Provider Information | |||||||||
NPI: | 1487022950 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA PAZ REGIONAL HOSPITAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVER HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 W MOHAVE RD | ||||||||
Address2: |   | ||||||||
City: | PARKER | ||||||||
State: | AZ | ||||||||
PostalCode: | 853446349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286697400 | ||||||||
FaxNumber: | 9286697409 | ||||||||
Practice Location | |||||||||
Address1: | 1200 W MOHAVE RD | ||||||||
Address2: |   | ||||||||
City: | PARKER | ||||||||
State: | AZ | ||||||||
PostalCode: | 853446349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286697380 | ||||||||
FaxNumber: | 9286697371 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2015 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9286697300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | HO138 | AZ | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QR1300X | HO138 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 222816 | 05 | AZ |   | MEDICAID |