Healthcare Provider Details

I. General information

NPI: 1922089416
Provider Name (Legal Business Name): HEART INSTITUTE OF NORTHERN ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 10/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1753 AIRWAY AVE SUITE B
KINGMAN AZ
86409-3720
US

IV. Provider business mailing address

10720 SIKES PL SUITE 300
CHARLOTTE NC
28277-8141
US

V. Phone/Fax

Practice location:
  • Phone: 928-692-6200
  • Fax: 928-692-9474
Mailing address:
  • Phone: 704-815-7789
  • Fax: 888-401-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY GUIDRY
Title or Position: CEO
Credential:
Phone: 704-815-7804