Provider Demographics
NPI:1063849388
Name:HAVASU NEUROLOGICAL CENTER PLLC
Entity Type:Organization
Organization Name:HAVASU NEUROLOGICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MAAME
Authorized Official - Middle Name:A
Authorized Official - Last Name:DANKWAH-QUANSAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-4040
Mailing Address - Street 1:297 LAKE HAVASU AVE S
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6526
Mailing Address - Country:US
Mailing Address - Phone:928-680-4040
Mailing Address - Fax:928-680-4484
Practice Address - Street 1:297 LAKE HAVASU AVE S
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6526
Practice Address - Country:US
Practice Address - Phone:928-680-4040
Practice Address - Fax:928-680-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP-1875159-0OtherCORPORATION NUMBER
AZ872509Medicaid