Healthcare Provider Details

I. General information

NPI: 1386190718
Provider Name (Legal Business Name): MONOLITH DIAGNOSTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 SYCAMORE AVE STE. C
KINGMAN AZ
86409-0942
US

IV. Provider business mailing address

PO BOX 6024
KINGMAN AZ
86402-6024
US

V. Phone/Fax

Practice location:
  • Phone: 928-263-3706
  • Fax: 928-263-3604
Mailing address:
  • Phone: 928-263-3706
  • Fax: 928-263-3604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number47589
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number47589
License Number StateAZ

VIII. Authorized Official

Name: RYAN E SWAPP
Title or Position: PRESIDENT
Credential:
Phone: 928-263-3706