Provider Demographics
NPI:1346944022
Name:BULLHEAD PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:BULLHEAD PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAKTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-704-9217
Mailing Address - Street 1:1355 RAMAR RD STE 11A
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7100
Mailing Address - Country:US
Mailing Address - Phone:928-704-9217
Mailing Address - Fax:
Practice Address - Street 1:1355 RAMAR RD STE 11A
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-704-9217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty