MEDICARE: QUAIL RIDGE MEDICAL LLC

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	111N00000X	Chiropractor
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1902270424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUAIL RIDGE MEDICAL LLC

Provider Business Mailing Address
First Line	:	2331 HUALAPAI MOUNTAIN RD
Second Line	:	SUITE A
City	:	KINGMAN
State	:	AZ
Zip	:	86401-6207
Country	:	US
Telephone Number	:	928-529-5086
Fax Number	:	928-529-5089

Provider Business Practice Location Address
First Line	:	2331 HUALAPAI MOUNTAIN RD
Second Line	:	SUITE A
City	:	KINGMAN
State	:	AZ
Zip	:	86401-6207
Country	:	US
Telephone Number	:	928-529-5086
Fax Number	:	928-529-5089

Authorized Official
Title or Position	:	OWNER/AUTHORIZED OFFICIAL
Name	:	MR. ERNEST SHAYNE MONSON
Credential	:	NP, DC
Telephone Number	:	928-529-5086

Provider Enumeration Date	:	11/20/2015
Last Update Date	:	07/15/2016

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