Provider Demographics
NPI:1629220504
Name:FREDONIA MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:FREDONIA MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-715-4311
Mailing Address - Street 1:201 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5844
Mailing Address - Country:US
Mailing Address - Phone:928-715-4311
Mailing Address - Fax:928-718-1986
Practice Address - Street 1:201 E SPRING ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5844
Practice Address - Country:US
Practice Address - Phone:928-715-4311
Practice Address - Fax:928-718-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ08709408261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1174517767OtherPERSONAL NPI NUMBER
AZF05227OtherUPIN