Provider Demographics
NPI:1275085284
Name:MOHAVE EYE CENTER, LTD
Entity Type:Organization
Organization Name:MOHAVE EYE CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WINTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-2106
Mailing Address - Street 1:2005 INJO DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5874
Mailing Address - Country:US
Mailing Address - Phone:928-753-2106
Mailing Address - Fax:928-753-4283
Practice Address - Street 1:1925 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4617
Practice Address - Country:US
Practice Address - Phone:928-753-2106
Practice Address - Fax:928-753-4283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOHAVE EYE CENTER, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1100290003OtherPTAN
AZZ20872OtherMEDICARE