Provider Demographics
NPI:1619633088
Name:INNOVATIVE PRIMARY CARE OF HAVASU LLC
Entity Type:Organization
Organization Name:INNOVATIVE PRIMARY CARE OF HAVASU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LOIDA
Authorized Official - Middle Name:LOYOLA
Authorized Official - Last Name:ARQUIZA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:240-535-0065
Mailing Address - Street 1:1945 MESQUITE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5889
Mailing Address - Country:US
Mailing Address - Phone:928-733-6287
Mailing Address - Fax:928-733-6305
Practice Address - Street 1:1945 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5889
Practice Address - Country:US
Practice Address - Phone:928-733-6287
Practice Address - Fax:928-733-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ258797OtherARIZONA NP LICENSE