Healthcare Provider Details

I. General information

NPI: 1962637710
Provider Name (Legal Business Name): HUALAPAI MOUNTAIN MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 SANTA ROSA
KINGMAN AZ
86401-2311
US

IV. Provider business mailing address

PO BOX 843719
DALLAS TX
75284-3719
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-2907
  • Fax: 928-757-2931
Mailing address:
  • Phone: 928-757-2907
  • Fax: 928-757-2931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD J FENTEM
Title or Position: VP, REVENUE CYCLE MANAGEMENT
Credential:
Phone: 972-702-7500