Provider Demographics
NPI:1780721613
Name:MOHAVE DESERT ORTHOPAEDIC CENTER LLC
Entity type:Organization
Organization Name:MOHAVE DESERT ORTHOPAEDIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMETT
Authorized Official - Middle Name:TERRANCE
Authorized Official - Last Name:MCELENEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-681-8681
Mailing Address - Street 1:1739 E BEVERLY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-681-8681
Mailing Address - Fax:928-681-8682
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-8681
Practice Address - Fax:928-681-8682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ07-4761OtherCITY LICENSE
AZ117024Medicare PIN
AZDG5127Medicare PIN