Healthcare Provider Details

I. General information

NPI: 1255582003
Provider Name (Legal Business Name): YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 CLEARWATER DR
PRESCOTT AZ
86305-7131
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-2400
  • Fax: 928-771-2650
Mailing address:
  • Phone: 928-759-5987
  • Fax: 928-458-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35954
License Number StateAZ

VIII. Authorized Official

Name: MR. LEE LIVIN
Title or Position: CFO
Credential:
Phone: 928-771-5691