MEDICARE: HAVASU PRIMARY CARE, LTD.

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	207Q00000X	Family Medicine Physician	43225	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16428743	OTHER	AZ	CORPORATION REGISTRATION

General Provider Information

NPI Number	:	1508169616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU PRIMARY CARE, LTD.

Provider Business Mailing Address
First Line	:	PO BOX 626
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-0626
Country	:	US
Telephone Number	:	928-453-0777
Fax Number	:	928-453-0778

Provider Business Practice Location Address
First Line	:	1830 MESQUITE AVE
Second Line	:	SUITE B
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5885
Country	:	US
Telephone Number	:	928-453-0777
Fax Number	:	928-453-0778

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MANU LONIAL
Credential	:	M.D.
Telephone Number	:	928-453-0777

Provider Enumeration Date	:	12/10/2010
Last Update Date	:	12/10/2010

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Directions to “HAVASU PRIMARY CARE, LTD. ” Practice Location

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