Provider Demographics
NPI:1174582829
Name:HAVASU FOOT & ANKLE CENTER
Entity type:Organization
Organization Name:HAVASU FOOT & ANKLE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVACK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
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:2006-03-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
490002545OtherMETRAHEALTH MEDICARE RR
490002545OtherMETRAHEALTH MEDICARE RR
Z3C0001048Medicare PIN