MEDICARE: KINGMAN KIDNEY CLINIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	OTC2527	AZ

General Provider Information

NPI Number	:	1447338710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGMAN KIDNEY CLINIC INC.

Provider Business Mailing Address
First Line	:	10917 72ND RD STE 6R
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-5336
Country	:	US
Telephone Number	:	718-268-6906
Fax Number	:

Provider Business Practice Location Address
First Line	:	4055 STOCKTON HILL RD STE 15
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-2469
Country	:	US
Telephone Number	:	928-692-6500
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RAMESH SARVA
Credential	:
Telephone Number	:	718-268-6906

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	06/03/2014

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