Provider Demographics
NPI:1407819857
Name:DOCTORS SURGERY CENTER OF KINGMAN, LLC
Entity Type:Organization
Organization Name:DOCTORS SURGERY CENTER OF KINGMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:E
Authorized Official - Last Name:MACHULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-681-4214
Mailing Address - Street 1:1740 SYCAMORE AVENUE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409
Mailing Address - Country:US
Mailing Address - Phone:928-681-4214
Mailing Address - Fax:928-681-4226
Practice Address - Street 1:1740 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0927
Practice Address - Country:US
Practice Address - Phone:928-681-4214
Practice Address - Fax:928-681-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC 2913261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0207340OtherBCBSAZ
AZ629420Medicaid
AZ629420Medicaid