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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1225301096
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	:	37027-5098
Country	:	US
Telephone Number	:	615-920-7000
Fax Number	:	615-920-8913

Provider Business Practice Location Address
First Line	:	1520 E HAMMER LN
Second Line	:	SUITE 102
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6664
Country	:	US
Telephone Number	:	928-788-4140
Fax Number	:	928-788-4148

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VICTOR E. GIOVANETTI
Credential	:
Telephone Number	:	615-920-7000

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	07/23/2015

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