Healthcare Provider Details

I. General information

NPI: 1902065303
Provider Name (Legal Business Name): LAKE HAVASU RADIOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W MOHAVE RD
PARKER AZ
85344-6349
US

IV. Provider business mailing address

PO BOX 1766
LAKE CHARLES LA
70602-1766
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-1961
  • Fax:
Mailing address:
  • Phone: 337-721-1961
  • Fax: 337-721-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VICKI CLOUD
Title or Position: BILLING MANAGER
Credential:
Phone: 337-721-1961