Provider Demographics
NPI:1740293950
Name:HAVASU REGIONAL MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:HAVASU REGIONAL MEDICAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:103 POWELL CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5079
Mailing Address - Country:US
Mailing Address - Phone:615-372-8500
Mailing Address - Fax:615-372-8572
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-855-8185
Practice Address - Fax:928-505-5768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVASU REGIONAL MEDICAL CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-15
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSH-2409273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXHSP33227Medicaid
CAXHSP43227Medicaid
AZ445131Medicaid
CAXHSP33227Medicaid