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General NPI Number Information
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NPI Number | 1033109863
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Entity Type | Organization
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Legal Business Name | HAVASU MEDICAL CARE
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Dates
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Enumeration Date | 10/24/2005
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 1955 MCCULLOCH BLVD N
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5748
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Country | US
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Telephone | 928-453-3007
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Fax | 928-680-9663
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Provider Business Mailing Address
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Address Line | 1955 MCCULLOCH BLVD N
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5748
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Country | US
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Telephone | 928-453-3007
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Fax | 928-680-9663
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Authorized Official
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Title or Position | M.D.
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Name | DR. MARY LOU CALLERAME II
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Credential | M.D.
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Telephone | 928-453-3007
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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