1760703805 NPI number — KINGMAN HEALTHCARE, INC

Table of content: (NPI 1760703805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760703805 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:
1760703805
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:
1739 E BEVERLY AVE STE 200
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:
86409-3593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-753-3303
Provider Business Mailing Address Fax Number:
928-753-3603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1726 E BEVERLY AVE STE A
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:
86409-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-753-3303
Provider Business Practice Location Address Fax Number:
928-753-3603
Provider Enumeration Date:
06/11/2010

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: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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