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General NPI Number Information
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NPI Number | 1700909330
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Entity Type | Organization
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Legal Business Name | MOHAVE PRIMARY CARE
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 975 SYCAMORE AVE
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City | KINGMAN
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State | AZ
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Zip | 86409-3548
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Country | US
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Telephone | 928-692-1900
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Fax | 928-692-7334
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Provider Business Mailing Address
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Address Line | 2183 SENECA ST
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City | KINGMAN
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State | AZ
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Zip | 86401-6511
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Country | US
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Telephone | 928-763-5948
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ILANGOVAN GOVINDARAJAN
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Credential | M.D.,CMD
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Telephone | 928-692-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25797
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License Number State | AZ
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