MEDICARE: MOHAVE NEURO REHAB CONSUL PC

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	2084N0400X	Neurology Physician
2	208100000X	Physical Medicine & Rehabilitation Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CE1180	OTHER	AZ	RR MEDICARE
2	Z21066	OTHER	AZ	MEDICARE PROV #

General Provider Information

NPI Number	:	1942291117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOHAVE NEURO REHAB CONSUL PC

Provider Business Mailing Address
First Line	:	1520 E HAMMER LN
Second Line	:	STE 106
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6664
Country	:	US
Telephone Number	:	928-681-6600
Fax Number	:	928-681-6606

Provider Business Practice Location Address
First Line	:	1520 E HAMMER LN
Second Line	:	STE 106
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6664
Country	:	US
Telephone Number	:	928-681-6600
Fax Number	:	928-681-6606

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS J. PARKS
Credential	:	MD
Telephone Number	:	928-681-6600

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	06/13/2008

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