Provider Demographics
NPI:1831121813
Name:HAVASU NURSING CENTER 2 INC
Entity Type:Organization
Organization Name:HAVASU NURSING CENTER 2 INC
Other - Org Name:HAVASU NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLIFF
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1276
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-1210
Mailing Address - Country:US
Mailing Address - Phone:573-471-1276
Mailing Address - Fax:573-472-8504
Practice Address - Street 1:3576 KEARSAGE DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-9115
Practice Address - Country:US
Practice Address - Phone:928-453-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNC1-355314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ041682Medicaid
AZ041682Medicaid