Basic Information
| Provider Information | |||||||||
| NPI: | 1588097349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE PRIMARY CARE CLINIC OF HAVASU PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27340 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850617340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 297 LAKE HAVASU AVE S | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864036526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288547666 | ||||||||
| FaxNumber: | 9288547660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2013 | ||||||||
| LastUpdateDate: | 08/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9288547666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | N.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | AP1654 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.