Provider Demographics
NPI:1194296558
Name:HILL, KIWANIS C
Entity type:Individual
Prefix:
First Name:KIWANIS
Middle Name:C
Last Name:HILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIWANIS
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6658 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6658 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3508
Practice Address - Country:US
Practice Address - Phone:520-971-3681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5564385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5564OtherAZ DEPT OF HEALTH SERVICES