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General NPI Number Information
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NPI Number | 1104064997
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Entity Type | Organization
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Legal Business Name | ARIZONA COAST RADIOLOGY, PLLC
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Dates
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Enumeration Date | 02/02/2009
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Last Update Date | 02/02/2009
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Provider Practice Location Address
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Address Line | 101 CIVIC CENTER LN
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5607
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Country | US
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Telephone | 928-412-7485
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 PATIO SIMPATICO
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-7789
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Country | US
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Telephone | 928-412-7485
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JACK D DUNN
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Credential | MD
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Telephone | 928-412-7485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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