Provider Demographics
NPI:1861020703
Name:SOUTHWEST EAR, NOSE & THROAT, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST EAR, NOSE & THROAT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-0303
Mailing Address - Street 1:1760 MCCULLOCH BLVD N STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6559
Mailing Address - Country:US
Mailing Address - Phone:928-453-0303
Mailing Address - Fax:928-453-0338
Practice Address - Street 1:1760 MCCULLOCH BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:928-453-0303
Practice Address - Fax:928-453-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty