Provider Demographics
NPI:1093348096
Name:SOUTHWEST EAR, NOSE, & THROAT SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHWEST EAR, NOSE, & THROAT SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-486-3934
Mailing Address - Street 1:2331 HOGAN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8242
Mailing Address - Country:US
Mailing Address - Phone:928-486-3934
Mailing Address - Fax:928-854-4462
Practice Address - Street 1:1760 MCCULLOCH BLVD N STE 100
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:928-854-5368
Practice Address - Fax:928-854-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ515877Medicaid