Healthcare Provider Details

I. General information

NPI: 1669146536
Provider Name (Legal Business Name): COLORADO RIVER PRIMARY CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E WAGON WHEEL LN STE 104
FORT MOHAVE AZ
86426-6698
US

IV. Provider business mailing address

1510 E WAGON WHEEL LN STE 104
FORT MOHAVE AZ
86426-6698
US

V. Phone/Fax

Practice location:
  • Phone: 928-248-0518
  • Fax: 928-514-2823
Mailing address:
  • Phone: 928-248-0518
  • Fax: 928-514-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: WANTZY COOPER
Title or Position: PRESIDENT
Credential: DO
Phone: 928-248-0518