Provider Demographics
NPI:1710919261
Name:LAKE HAVASU IMAGING CENTER INC
Entity Type:Organization
Organization Name:LAKE HAVASU IMAGING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-505-9729
Mailing Address - Street 1:1944 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5729
Mailing Address - Country:US
Mailing Address - Phone:928-505-9729
Mailing Address - Fax:928-505-9200
Practice Address - Street 1:1944 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-505-9729
Practice Address - Fax:928-505-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ583729Medicaid
AZ470000882OtherRAIL ROAD MEDICARE