Healthcare Provider Details

I. General information

NPI: 1093348096
Provider Name (Legal Business Name): SOUTHWEST EAR, NOSE, & THROAT SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 MCCULLOCH BLVD N STE 100
LAKE HAVASU CITY AZ
86403-6559
US

IV. Provider business mailing address

2331 HOGAN LN
LAKE HAVASU CITY AZ
86406-8242
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5368
  • Fax: 928-854-4462
Mailing address:
  • Phone: 928-486-3934
  • Fax: 928-854-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE ADAIR PRATER
Title or Position: MANAGER
Credential:
Phone: 928-486-3934