Provider Demographics
NPI:1225205065
Name:PHC-FORT MOHAVE INC
Entity Type:Organization
Organization Name:PHC-FORT MOHAVE INC
Other - Org Name:VALLEY VIEW MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:5330 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9225
Mailing Address - Country:US
Mailing Address - Phone:928-788-7845
Mailing Address - Fax:928-788-2273
Practice Address - Street 1:5330 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9225
Practice Address - Country:US
Practice Address - Phone:928-788-7845
Practice Address - Fax:928-788-2273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHC-FORT MOHAVE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104567Medicaid
CAXSHP33833Medicaid
CAXHSP43833Medicaid
AZ104567Medicaid