=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346944022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BULLHEAD PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2023
-----------------------------------------------------
Last Update Date | 03/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1355 RAMAR RD STE 11A
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-704-9217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1355 RAMAR RD STE 11A
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-704-9217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. SHAKTI SONI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-704-9217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------