Healthcare Provider Details

I. General information

NPI: 1972825644
Provider Name (Legal Business Name): HAVASU REGIONAL MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1799 KIOWA AVE # 104
LAKE HAVASU CITY AZ
86403-2881
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-4536
US

V. Phone/Fax

Practice location:
  • Phone: 928-505-1030
  • Fax:
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberAPPLIED FOR
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAPPLIED FOR
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberAPPLIED FOR
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberAPPLIED FOR
License Number StateAZ

VIII. Authorized Official

Name: TERRANCE DILLON
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 502-596-7220