Provider Demographics
NPI:1164690335
Name:HAVASU FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:HAVASU FOOT & ANKLE CENTER
Other - Org Name:ROBERT H NOVACK, DPM
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:NOVACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-855-7800
Mailing Address - Street 1:90 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5716
Mailing Address - Country:US
Mailing Address - Phone:928-855-7800
Mailing Address - Fax:928-855-5392
Practice Address - Street 1:90 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5716
Practice Address - Country:US
Practice Address - Phone:928-855-7800
Practice Address - Fax:928-855-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0180332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
480016799Medicare PIN
T41990Medicare UPIN
0414850001Medicare NSC