Provider Demographics
NPI:1538347836
Name:KINGMAN HEALTHCARE, INC
Entity type:Organization
Organization Name:KINGMAN HEALTHCARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-681-8668
Mailing Address - Street 1:3269 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-0626
Mailing Address - Fax:928-692-2706
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-0626
Practice Address - Fax:928-692-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHSPC4872251G00000X
AZSPC3040251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP0702260OtherBCBS
AZ722878Medicaid