Healthcare Provider Details

I. General information

NPI: 1821902891
Provider Name (Legal Business Name): ALICE JUDY EKLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3854 N PRESCOTT ST
KINGMAN AZ
86409-3339
US

IV. Provider business mailing address

3854 N PRESCOTT ST
KINGMAN AZ
86409-3339
US

V. Phone/Fax

Practice location:
  • Phone: 307-887-9090
  • Fax:
Mailing address:
  • Phone: 307-887-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number660397
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: