Healthcare Provider Details

I. General information

NPI: 1770678401
Provider Name (Legal Business Name): KINGMAN ACADEMY OF LEARNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 E BEVERLY AVE
KINGMAN AZ
86409-0736
US

IV. Provider business mailing address

2299 E BEVERLY AVE
KINGMAN AZ
86409-0736
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-2400
  • Fax: 928-681-2424
Mailing address:
  • Phone: 928-681-2400
  • Fax: 928-681-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. DEAN JONATHAN COLVIG
Title or Position: NCLB/SPECIAL PROGRAM COORDINATOR
Credential:
Phone: 928-681-2400