Provider Demographics
NPI:1154051753
Name:SAN LUIS WALK-IN CLINIC, INC.
Entity Type:Organization
Organization Name:SAN LUIS WALK-IN CLINIC, INC.
Other - Org Name:LAKE HAVASU PEDIATRIC FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-315-7910
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1980 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-7713
Practice Address - Country:US
Practice Address - Phone:928-392-3691
Practice Address - Fax:928-392-3693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty