Provider Demographics
NPI:1669438867
Name:OPEN MRI OF LAKE HAVASU LLC
Entity Type:Organization
Organization Name:OPEN MRI OF LAKE HAVASU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-990-2629
Mailing Address - Street 1:604B MADISON ST SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4401
Mailing Address - Country:US
Mailing Address - Phone:256-533-2311
Mailing Address - Fax:256-533-2231
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6717
Practice Address - Country:US
Practice Address - Phone:928-505-1511
Practice Address - Fax:928-505-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC39302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ089276Medicaid
AZOTC3930OtherAZ DEPT OF HEALTH SVC
AZAZ0155710OtherBLUE CROSS
ALP00308294OtherMEDICARE RR PALMETTO GBA
AZOTC3930OtherAZ DEPT OF HEALTH SVC
ALP00308294OtherMEDICARE RR PALMETTO GBA