Provider Demographics
NPI:1518990902
Name:YUMA HEART INSTITITUTE LLC
Entity Type:Organization
Organization Name:YUMA HEART INSTITITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-3350
Mailing Address - Street 1:2503 S AVENUE A
Mailing Address - Street 2:SUITE #2
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-344-3350
Mailing Address - Fax:928-344-2270
Practice Address - Street 1:2503 S AVE A
Practice Address - Street 2:SUITE #2
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-344-3350
Practice Address - Fax:928-344-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ759001Medicare PIN
AZZ75661Medicare PIN
AZZ75662Medicare PIN
AZZ75901Medicare PIN
AZZWMBMSMedicare PIN