Healthcare Provider Details

I. General information

NPI: 1235721531
Provider Name (Legal Business Name): COLTON HEALTH AZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
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

1755 AIRWAY AVE
KINGMAN AZ
86409-3620
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-1234
  • Fax: 928-681-1811
Mailing address:
  • Phone: 480-553-6263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: SUKHJIT SINGH GHUMAN
Title or Position: OWNER
Credential:
Phone: 480-609-4200