Basic Information
| Provider Information | |||||||||
| NPI: | 1811086994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHC-FORT MOHAVE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY VIEW MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 5330 S HIGHWAY 95 | ||||||||
| Address2: | |||||||||
| City: | FORT MOHAVE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864269225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287882273 | ||||||||
| FaxNumber: | 9287882273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H3864 | AZ | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | XHSP38333 | 05 | CA | MEDICAID | XHSP43833 | 05 | CA | MEDICAID | 104567 | 05 | AZ | MEDICAID |