Provider Demographics
NPI:1174701478
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:928-263-4722
Mailing Address - Fax:928-263-4794
Practice Address - Street 1:2202 N STOCKTON HILL RD STE 200
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4622
Practice Address - Country:US
Practice Address - Phone:928-757-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGMAN HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-08
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA0059251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738156Medicaid
AZP0074390OtherBCBS