Healthcare Provider Details

I. General information

NPI: 1528394830
Provider Name (Legal Business Name): YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 AINSWORTH DR SUITE A
PRESCOTT AZ
86301-1623
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-6025
  • Fax: 928-778-3026
Mailing address:
  • Phone: 928-759-5987
  • Fax: 928-458-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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