1689897787 NPI number — KINGMAN HEALTHCARE, INC

Table of content: (NPI 1689897787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689897787 NPI number — KINGMAN HEALTHCARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGMAN HEALTHCARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KINGMAN HOSPITAL, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689897787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3269 N STOCKTON HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGMAN
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86409-3619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-263-4722
Provider Business Mailing Address Fax Number:
928-263-4794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1739 BEVERLY AVENUE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86409-3593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-263-4547
Provider Business Practice Location Address Fax Number:
928-263-4794
Provider Enumeration Date:
04/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HUSTED
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
Authorized Official Title or Position:
CBO BILLING MANAGER
Authorized Official Telephone Number:
928-263-4735

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 399256 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".