Basic Information
| Provider Information | |||||||||
| NPI: | 1740293950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAVASU REGIONAL MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HAVASU REGIONAL MEDICAL CENTER REHABILITATION PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 103 POWELL CT | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153728500 | ||||||||
| FaxNumber: | 6153728572 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 CIVIC CENTER LN | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864035607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288558185 | ||||||||
| FaxNumber: | 9285055768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HAVASU REGIONAL MEDICAL CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | SH-2409 | AZ | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | XHSP33227 | 05 | CA | MEDICAID | XHSP43227 | 05 | CA | MEDICAID | 445131 | 05 | AZ | MEDICAID |