Healthcare Provider Details

I. General information

NPI: 1538338058
Provider Name (Legal Business Name): FPS MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 LAKE HAVASU AVE S STE 204
LAKE HAVASU CITY AZ
86403-6526
US

IV. Provider business mailing address

297 LAKE HAVASU AVE S STE 204
LAKE HAVASU CITY AZ
86403-6526
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-1970
  • Fax: 928-855-7229
Mailing address:
  • Phone: 928-453-1970
  • Fax: 928-855-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIE PATRICK
Title or Position: PRACTICE MANAGER
Credential:
Phone: 928-453-1970