Basic Information
| Provider Information | |||||||||
| NPI: | 1942228473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA PAZ REGIONAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LA PAZ INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W MOHAVE RD | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853446349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286699201 | ||||||||
| FaxNumber: | 9286697417 | ||||||||
| Practice Location | |||||||||
| Address1: | 1713 S KOFA AVE STE J | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853446400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286696299 | ||||||||
| FaxNumber: | 9286691623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 06/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | BOWN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9286697300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | H0138 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 187163 | 05 | AZ | MEDICAID | CG7880 | 01 | AZ | MEDICARE RR | OTHER |