=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710919261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE HAVASU IMAGING CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1944 MESQUITE AVE
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-505-9729
-----------------------------------------------------
Fax | 928-505-9200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1944 MESQUITE AVE
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-505-9729
-----------------------------------------------------
Fax | 928-505-9200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SYLVIA HEINER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-505-9729
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------