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General NPI Number Information
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NPI Number | 1467637280
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Entity Type | Organization
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Legal Business Name | SOUTHWEST NEUROLOGY P C
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Dates
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Enumeration Date | 12/31/2007
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 5300 S HIGHWAY 95 SUITE L
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-9251
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Country | US
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Telephone | 928-788-4260
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Fax | 928-788-4262
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Provider Business Mailing Address
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Address Line | PO BOX 10499
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City | FORT MOHAVE
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State | AZ
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Zip | 86427-0499
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Country | US
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Telephone | 928-788-4260
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Fax | 928-788-4262
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RONALD S. BENNETT
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Credential | M.D.
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Telephone | 928-788-4260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 22788
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License Number State | AZ
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