Provider Demographics
NPI:1003113010
Name:ARIZONA COAST WIDE OPEN MRI, PLLC
Entity Type:Organization
Organization Name:ARIZONA COAST WIDE OPEN MRI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-669-7480
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0039
Mailing Address - Country:US
Mailing Address - Phone:928-535-6667
Mailing Address - Fax:928-535-5561
Practice Address - Street 1:2130 MESQUITE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6897
Practice Address - Country:US
Practice Address - Phone:602-943-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ605261Medicaid
AZZ146172OtherMEDICARE PTAN