Healthcare Provider Details

I. General information

NPI: 1649464454
Provider Name (Legal Business Name): YAVAPAI COMMUNITY HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 AINSWORTH DRIVE STE. 103
PRESCOTT AZ
86301-1624
US

IV. Provider business mailing address

1003 WILLOW CREEK ROAD
PRESCOTT AZ
86301-1641
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-2700
  • Fax: 928-771-5785
Mailing address:
  • Phone: 928-771-5695
  • Fax: 928-458-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH3964
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH0115
License Number StateAZ

VIII. Authorized Official

Name: MR. LEE LIVIN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 928-771-5691