Provider Demographics
NPI:1043369168
Name:MOHAVE FAMILY HEALTHCARE
Entity type:Organization
Organization Name:MOHAVE FAMILY HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:D.O./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-768-9496
Mailing Address - Street 1:PO BOX 9479
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-9479
Mailing Address - Country:US
Mailing Address - Phone:928-768-9496
Mailing Address - Fax:928-768-1943
Practice Address - Street 1:1611 E JOY LN
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8807
Practice Address - Country:US
Practice Address - Phone:928-768-9496
Practice Address - Fax:928-768-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z71871Medicare PIN