Provider Demographics
NPI:1447338710
Name:KINGMAN KIDNEY CLINIC INC.
Entity type:Organization
Organization Name:KINGMAN KIDNEY CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SARVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-268-6906
Mailing Address - Street 1:10917 72ND RD STE 6R
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5336
Mailing Address - Country:US
Mailing Address - Phone:718-268-6906
Mailing Address - Fax:
Practice Address - Street 1:4055 STOCKTON HILL RD STE 15
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2469
Practice Address - Country:US
Practice Address - Phone:928-692-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC2527261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ032582Medicare Oscar/Certification