Provider Demographics
NPI:1962637710
Name:HUALAPAI MOUNTAIN MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:HUALAPAI MOUNTAIN MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FENTEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-702-7500
Mailing Address - Street 1:PO BOX 843719
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-3719
Mailing Address - Country:US
Mailing Address - Phone:928-757-2907
Mailing Address - Fax:928-757-2931
Practice Address - Street 1:3801 SANTA ROSA
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-2311
Practice Address - Country:US
Practice Address - Phone:928-757-2907
Practice Address - Fax:928-757-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030128Medicare Oscar/Certification