Provider Demographics
NPI:1225881113
Name:ACADEMIC HEALTH INC
Entity Type:Organization
Organization Name:ACADEMIC HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:HANZ
Authorized Official - Middle Name:
Authorized Official - Last Name:TABORA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-994-5560
Mailing Address - Street 1:1510 E WAGON WHEEL LN STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1510 E WAGON WHEEL LN STE 104
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6698
Practice Address - Country:US
Practice Address - Phone:928-248-0518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care