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General NPI Number Information
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NPI Number | 1508169616
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Entity Type | Organization
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Legal Business Name | HAVASU PRIMARY CARE, LTD.
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Dates
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Enumeration Date | 12/10/2010
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Last Update Date | 12/10/2010
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Provider Practice Location Address
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Address Line | 1830 MESQUITE AVE SUITE B
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5885
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Country | US
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Telephone | 928-453-0777
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Fax | 928-453-0778
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Provider Business Mailing Address
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Address Line | PO BOX 626
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86405-0626
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Country | US
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Telephone | 928-453-0777
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Fax | 928-453-0778
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Authorized Official
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Title or Position | PRESIDENT
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Name | MANU LONIAL
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Credential | M.D.
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Telephone | 928-453-0777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 43225
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License Number State | AZ
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