1639105893 NPI number — WIDE OPEN MRI OF BULLHEAD CITY LLC

Table of content: (NPI 1639105893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639105893 NPI number — WIDE OPEN MRI OF BULLHEAD CITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIDE OPEN MRI OF BULLHEAD CITY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639105893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 HIGHWAY 95
Provider Second Line Business Mailing Address:
SUITE 222
Provider Business Mailing Address City Name:
BULLHEAD CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86442-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-704-0080
Provider Business Mailing Address Fax Number:
928-704-1654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 HIGHWAY 95
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
BULLHEAD CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86442-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-704-0080
Provider Business Practice Location Address Fax Number:
928-704-1654
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CYRUS
Authorized Official First Name:
JASON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-704-0080

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 912776 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0769960 . This is a "BLUE CROSS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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