MEDICARE: HAILEY H ELDRIDGE

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1285202754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAILEY H ELDRIDGE

Provider Business Mailing Address
First Line	:	4304 S RAFE AVE
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-5381
Country	:	US
Telephone Number	:	928-278-7515
Fax Number	:

Provider Business Practice Location Address
First Line	:	4304 S RAFE AVE
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-5381
Country	:	US
Telephone Number	:	928-278-7515
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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Directions to “ HAILEY H ELDRIDGE ” Practice Location

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