Provider Demographics
NPI:1104152768
Name:CARDIAC AND VASCULAR ASSOCIATES LLC
Entity type:Organization
Organization Name:CARDIAC AND VASCULAR ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MELVYN
Authorized Official - Middle Name:V
Authorized Official - Last Name:MAHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-730-6790
Mailing Address - Street 1:301 NORTHLAKE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6009
Mailing Address - Country:US
Mailing Address - Phone:803-730-6790
Mailing Address - Fax:803-736-5536
Practice Address - Street 1:1851 MESQUITE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5677
Practice Address - Country:US
Practice Address - Phone:928-855-5090
Practice Address - Fax:928-855-9227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL1560391-7OtherCORPORATION NUMBER