| NPI |
1780179044 |
The first name of the provider, if the provider
is an individual. |
| Entity Type Code |
2 |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Employer Identification Number EIN |
|
The city name in the location address of the provider being identified. |
| Provider Organization Name Legal Business Name |
MOUNTAIN VALLEY REGIONAL REHABILITATION HOSPITAL INC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Other Organization Name |
MVRRH PHYSICIAN GROUP |
Other name by which the organization provider is or has been known. |
| Provider Other Organization Name Type Code |
3 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
| Provider First Line Business Practice Location Address |
3700 N WINDSONG DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
PRESCOTT VALLEY |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
AZ |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Postal Code |
863141253 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
9287598800 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
6/28/2018 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
6/29/2023 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
KANN |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
DENISE |
The first name of the authorized official. |
| Authorized Official Title or Position |
VICE PRESIDENT AND SECRETARY |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
9722162299 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
261QM1300X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Organization Subpart |
N |
|
| NPI Certification Date |
6/29/2023 |
|