MEDICARE: PHC-FORT MOHAVE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital	H3864	AZ

General Provider Information

NPI Number	:	1164732517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHC-FORT MOHAVE, INC.

Provider Business Mailing Address
First Line	:	330 SEVEN SPRINGS WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4536
Country	:	US
Telephone Number	:	615-920-7000
Fax Number	:	615-920-8913

Provider Business Practice Location Address
First Line	:	5330 SOUTH HIGHWAY 95
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427-9232
Country	:	US
Telephone Number	:	928-788-2273
Fax Number	:	928-788-7845

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT N KLEIN
Credential	:
Telephone Number	:	615-920-7000

Provider Enumeration Date	:	10/19/2010
Last Update Date	:	03/09/2017

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