Healthcare Provider Details

I. General information

NPI: 1194988824
Provider Name (Legal Business Name): MOUNTAIN HEART CATH LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S THOMPSON ST
FLAGSTAFF AZ
86001-8759
US

IV. Provider business mailing address

2000 S THOMPSON ST
FLAGSTAFF AZ
86001-8759
US

V. Phone/Fax

Practice location:
  • Phone: 928-226-6400
  • Fax: 928-226-6411
Mailing address:
  • Phone: 928-226-6400
  • Fax: 928-226-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number30420
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QR0404X
TaxonomyCardiac Rehabilitation Clinic/Center
License Number30420
License Number StateAZ

VIII. Authorized Official

Name: SUZANNE R DUVAL
Title or Position: CREDENTIALING
Credential:
Phone: 928-226-6400