Provider Demographics
NPI:1265423917
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 N 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:928-681-8655
Mailing Address - Fax:928-263-3599
Practice Address - Street 1:3269 N 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:928-681-8655
Practice Address - Fax:928-263-3599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA0059251E00000X
AZSPC3040251G00000X
AZ137455293D00000X
AZH0010282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ184755Medicaid
AZ020256Medicaid
AZ030055Medicare Oscar/Certification
AZ020256Medicaid
031552Medicare ID - Type UnspecifiedMEDICARE HOSPICE
AZ03T055Medicare UPIN
AZ037050Medicare ID - Type UnspecifiedHOME HEALTH
75817Medicare ID - Type Unspecified
AZ184755Medicaid
AZ03T055Medicare Oscar/Certification
AZ0690840001Medicare Oscar/Certification