Organization
OPEN MRI OF LAKE HAVASU LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TOMMY R HARRIS (MANAGING MEMBER)
(256) 990-2629
Entity
Organization
Contact information
Practice address
2082 MESQUITE AVE, SUITE 114, LAKE HAVASU CITY, AZ 86403-6717
(928) 505-1511
(928) 505-1541
Mailing address
604B MADISON ST SE, HUNTSVILLE, AL 35801-4401
(256) 533-2311
(256) 533-2231
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
OTC3930
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
089276
—
AZ
01
—
AZ0155710
BLUE CROSS
AZ
01
—
OTC3930
AZ DEPT OF HEALTH SVC
AZ
01
—
P00308294
MEDICARE RR PALMETTO GBA
AL
Enumeration date
04/25/2006
Last updated
02/22/2008
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