Healthcare Provider Details

I. General information

NPI: 1992901672
Provider Name (Legal Business Name): OB-GYN WOMEN'S CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HIGHWAY 95 SUITE 39
BULLHEAD CITY AZ
86429
US

IV. Provider business mailing address

3003 HIGHWAY 95 SUITE 39
BULLHEAD CITY AZ
86429
US

V. Phone/Fax

Practice location:
  • Phone: 928-758-1010
  • Fax: 928-758-1428
Mailing address:
  • Phone: 928-758-1010
  • Fax: 928-758-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DIANE PITUCH IMMESBERGER
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 928-514-8602