Healthcare Provider Details

I. General information

NPI: 1619487675
Provider Name (Legal Business Name): YAVAPAI HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 DIVISION STREET
PRESCOTT AZ
86301
US

IV. Provider business mailing address

50 VANDERBILT MOTOR PKWY
COMMACK NY
11725
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-9600
  • Fax: 928-777-9797
Mailing address:
  • Phone: 631-352-0650
  • Fax: 631-343-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL O'NEIL
Title or Position: SOLE MBR/CEO
Credential:
Phone: 631-352-0650