1174701478 NPI number — KINGMAN HEALTHCARE, INC

Table of content: (NPI 1174701478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174701478 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:
1174701478
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:
2202 N STOCKTON HILL RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86401-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-757-0630
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLANCHARD
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
928-681-8668

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA0059 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 738156 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0074390 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".