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General NPI Number Information
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NPI Number | 1669146536
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Entity Type | Organization
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Legal Business Name | COLORADO RIVER PRIMARY CARE, INC
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Dates
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Enumeration Date | 08/04/2021
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Last Update Date | 03/04/2024
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Provider Practice Location Address
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Address Line | 1510 E WAGON WHEEL LN STE 104
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-6698
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Country | US
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Telephone | 928-248-0518
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Fax | 928-514-2823
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Provider Business Mailing Address
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Address Line | 1510 E WAGON WHEEL LN STE 104
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-6698
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Country | US
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Telephone | 928-248-0518
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Fax | 928-514-2823
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Authorized Official
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Title or Position | PRESIDENT
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Name | WANTZY COOPER
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Credential | DO
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Telephone | 928-248-0518
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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