Healthcare Provider Details

I. General information

NPI: 1124635396
Provider Name (Legal Business Name): COLTON HEALTH AZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 AIRWAY AVE
KINGMAN AZ
86409-3588
US

IV. Provider business mailing address

9457 E ADOBE DR
SCOTTSDALE AZ
85255-5077
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-1234
  • Fax: 928-681-1811
Mailing address:
  • Phone: 602-702-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SUKHJIT SINGH GHUMAN
Title or Position: GROUP CHAIRMAN AND CEO
Credential:
Phone: 602-702-3955