Provider Demographics
NPI:1467673293
Name:HAVASU REGIONAL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:HAVASU REGIONAL MEDICAL CENTER LLC
Other - Org Name:HAVASU SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4536
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8913
Practice Address - Street 1:1775 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6549
Practice Address - Country:US
Practice Address - Phone:928-855-8185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVASU REGIONAL MEDICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231644Medicaid
AZ03C0001245Medicare Oscar/Certification
114564Medicare PIN