MEDICARE: PHC-LAKE HAVASU INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	HHA0063	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245343482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHC-LAKE HAVASU INC

Provider Business Mailing Address
First Line	:	330 SEVEN SPRINGS WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4536
Country	:	US
Telephone Number	:	615-920-7000
Fax Number	:	615-920-8913

Provider Business Practice Location Address
First Line	:	1851 MESQUITE AVE
Second Line	:	STE. 206
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5677
Country	:	US
Telephone Number	:	928-680-1209
Fax Number	:	928-680-7914

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VICTOR E. GIOVANETTI
Credential	:
Telephone Number	:	615-920-7000

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	07/23/2015

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Directions to “PHC-LAKE HAVASU INC ” Practice Location

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