=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265423917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGMAN HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 07/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3269 N STOCKTON HILL RD
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86409-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-681-8655
-----------------------------------------------------
Fax | 928-263-3599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3269 N STOCKTON HILL RD
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86409-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-681-8655
-----------------------------------------------------
Fax | 928-263-3599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TIM BLANCHARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-681-8668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HHA0059
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | SPC3040
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 137455
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | H0010
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------