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General NPI Number Information
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NPI Number | 1598944811
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Entity Type | Organization
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Legal Business Name | LAKE HAVASU OB/GYN, PC
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Dates
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Enumeration Date | 11/02/2007
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Last Update Date | 02/29/2012
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Provider Practice Location Address
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Address Line | 99 RIVIERA DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5713
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Country | US
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Telephone | 928-680-2846
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Fax | 928-680-2845
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Provider Business Mailing Address
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Address Line | 99 RIVIERA DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5713
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Country | US
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Telephone | 928-680-2846
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Fax | 928-680-2845
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY JO VITA URSO
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Credential | D.O.
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Telephone | 928-680-2846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 20A8265
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 3696
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License Number State | AZ
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