Healthcare Provider Details

I. General information

NPI: 1700240884
Provider Name (Legal Business Name): BULLHEAD CITY CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 S CASINO DR SUITE 118
LAUGHLIN NV
89029-1560
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 702-299-7203
  • Fax: 702-299-7212
Mailing address:
  • Phone: 615-778-8075
  • Fax: 615-628-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SWAW
Title or Position: DIRECTOR
Credential:
Phone: 615-778-8076