Provider Demographics
NPI:1386834844
Name:MOHAVE MEDICAL ONCOLOGY CENTER
Entity Type:Organization
Organization Name:MOHAVE MEDICAL ONCOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:LINN
Authorized Official - Last Name:KONIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-471-7779
Mailing Address - Street 1:PO BOX 777550
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89077-7550
Mailing Address - Country:US
Mailing Address - Phone:702-471-7779
Mailing Address - Fax:702-471-0484
Practice Address - Street 1:3801 SANTA ROSA
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-2311
Practice Address - Country:US
Practice Address - Phone:702-471-7779
Practice Address - Fax:702-471-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD18958207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ056037Medicaid
AZMD18958Medicare PIN
AZ056037Medicaid