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General NPI Number Information
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NPI Number | 1205891124
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Entity Type | Organization
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Legal Business Name | HAVASU MEDICAL SUPPLY INC.
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 10/10/2008
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Provider Practice Location Address
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Address Line | 1849 ACOMA BLVD W STE 116
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-3184
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Country | US
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Telephone | 928-854-1868
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Fax | 928-854-1865
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Provider Business Mailing Address
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Address Line | 1849 ACOMA BLVD W STE 116
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-3184
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Country | US
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Telephone | 928-854-1868
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Fax | 928-854-1865
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Authorized Official
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Title or Position | OWNER RT
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Name | MR. JIM JAY GOLDMAN
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Credential | CRT
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Telephone | 928-854-1868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 332B00000X
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License Number State | AZ
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