Basic Information
| Provider Information | |||||||||
| NPI: | 1174701478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGMAN HEALTHCARE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINGMAN HOSPITAL, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3269 N STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282634722 | ||||||||
| FaxNumber: | 9282634794 | ||||||||
| Practice Location | |||||||||
| Address1: | 2202 N STOCKTON HILL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287570630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLANCHARD | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9286818668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINGMAN HEALTHCARE, INC | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HHA0059 | AZ | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 738156 | 05 | AZ | MEDICAID | P0074390 | 01 | AZ | BCBS | OTHER |