MEDICARE: CENTRAL MOHAVE MEDICAL CLINICS LTD

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	207Q00000X	Family Medicine Physician	13105	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427264480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MOHAVE MEDICAL CLINICS LTD

Provider Business Mailing Address
First Line	:	1915 STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4652
Country	:	US
Telephone Number	:	928-753-6668
Fax Number	:	928-753-9797

Provider Business Practice Location Address
First Line	:	1915 N STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4652
Country	:	US
Telephone Number	:	928-753-6668
Fax Number	:	928-753-9797

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MICHAEL MASTAKAS
Credential	:	M.D.
Telephone Number	:	928-753-6668

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	09/17/2009

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