Healthcare Provider Details

I. General information

NPI: 1265423917
Provider Name (Legal Business Name): KINGMAN HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

IV. Provider business mailing address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-8655
  • Fax: 928-263-3599
Mailing address:
  • Phone: 928-681-8655
  • Fax: 928-263-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHHA0059
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License NumberSPC3040
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number137455
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberH0010
License Number StateAZ

VIII. Authorized Official

Name: TIM BLANCHARD
Title or Position: CFO
Credential:
Phone: 928-681-8668