Provider Demographics
NPI:1609207075
Name:YOUR HEALTH HOME PLLC
Entity Type:Organization
Organization Name:YOUR HEALTH HOME PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-3343
Mailing Address - Street 1:PO BOX 1969
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1969
Mailing Address - Country:US
Mailing Address - Phone:928-680-3343
Mailing Address - Fax:928-680-3342
Practice Address - Street 1:2035 MESQUITE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-680-3343
Practice Address - Fax:928-680-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP-18894563OtherPLLC REGISTRATION NUMBER
AZ885211Medicaid