Provider Demographics
NPI:1366450199
Name:KINGMAN HEALTH CLINIC, P.A.
Entity Type:Organization
Organization Name:KINGMAN HEALTH CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-532-5145
Mailing Address - Street 1:701 E A AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1723
Mailing Address - Country:US
Mailing Address - Phone:620-532-5145
Mailing Address - Fax:620-532-2586
Practice Address - Street 1:701 E A AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1723
Practice Address - Country:US
Practice Address - Phone:620-532-5145
Practice Address - Fax:620-532-2586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100397910AMedicaid
KS110669OtherBC/BS
KS110669OtherBC/BS