Provider Demographics
NPI:1538241914
Name:PHC-FORT MOHAVE INC
Entity type:Organization
Organization Name:PHC-FORT MOHAVE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8913
Practice Address - Street 1:5330 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9225
Practice Address - Country:US
Practice Address - Phone:928-788-2273
Practice Address - Fax:928-788-7845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHC-FORT MOHAVE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSH4026273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03T117Medicare Oscar/Certification