Healthcare Provider Details

I. General information

NPI: 1285452516
Provider Name (Legal Business Name): ACADEMIC HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/23/2024
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: 928-889-2273
  • Fax: 928-212-1355
Mailing address:
  • Phone: 928-889-2273
  • Fax: 928-212-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HANZ KONRAD TABORA
Title or Position: ADMIN
Credential: PT
Phone: 904-994-5560