Healthcare Provider Details

I. General information

NPI: 1538241914
Provider Name (Legal Business Name): PHC-FORT MOHAVE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 S HIGHWAY 95
FORT MOHAVE AZ
86426-9225
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 928-788-2273
  • Fax: 928-788-7845
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberSH4026
License Number StateAZ

VIII. Authorized Official

Name: CHARLOTTE LAWRENCE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7000