Kingman No 1 LLC
Organization Active NPI Skilled Nursing Facility · Kingman, AZ
NPI 1184656175 · NPPES record last updated Jan 3, 2017
Key facts
- NPI
- 1184656175
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- License
- NCI306 (AZ)
- Legal business name
- KINGMAN NO 1 LLC
- Practice address
- 1081 Kathleen Ave
Kingman, AZ 86401-3918 - Phone
- (928) 753-5580
- NPI assigned
- Jul 7, 2006
- Organization subpart
- No
Authorized official
- Name
- Cliff Shirrell
- Title
- Vice President
- Phone
- (573) 471-1276
Owners & managing parties with NPI records 2
-
Daniel Itano, D.O.
Facilities with the same owner 41
Practitioners 3
-
Daniel Itano, D.O.
-
Thomas F. Garland, M.D.
-
John A Weidner, D.O.
Affiliated clinicians 2
-
Daniel Itano, D.O.
-
John A Weidner, D.O.
Medicare Care Compare: Nursing home
- Listed as
- Desert Highlands Care Center
- Overall star rating
- ★★★☆☆ 3 of 5
- Health inspections
- ★★★☆☆ 3 of 5
- Staffing
- ★★★☆☆ 3 of 5
- Quality measures
- ★★★☆☆ 3 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Certified
- May 23, 1988
- Medicare certification status
- Active
- Certified beds
- 120 · 74.5 residents per day on average
- Chain
- Circle B Enterprises
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 03D0534290 | Desert Highlands Care Center | Certificate of waiver | Jul 7, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Skilled nursing facility certification: CCN 035169
- Legal name
- KINGMAN NO 1 LLC
- Doing business as
- DESERT HIGHLANDS CARE CENTER
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- May 23, 1988
- Last certification
- Mar 14, 2025
- Beds
- 120
- Ownership / control type
- Limited Liability Corporation
- Multi-facility organization
- Avant Guard
- Organization structure
- LLC · Proprietary
- Enrollment address
- 1081 Kathleen Ave
Kingman, AZ 86401-3918 - Nursing home name
- DESERT HIGHLANDS CARE CENTER
- Affiliated entity
- CIRCLE B ENTERPRISES
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| |
Adp of the SNF | Jan 1, 2000 | |
| Kingman Properties LLC |
Adp of the SNF | Jan 1, 2010 | |
| Helen Blackwell-Scott |
Operational/Managerial Control | Mar 13, 2023 | |
| Adp of the SNF | Mar 13, 2023 | ||
| Sovereign Healthcare Group LLC |
Operational/Managerial Control | Apr 23, 2021 | |
| Adp of the SNF | Apr 3, 2025 | ||
| FG LLC |
Adp of the SNF | Dec 2, 2016 | |
| Mid States Inc |
Adp of the SNF | Nov 1, 2010 | |
| Van de Ven LLC |
Adp of the SNF | Jan 1, 2000 | |
| Circle B Enterprises Holding Company Inc |
5% Or Greater Direct Ownership Interest | Jul 5, 2000 | 100% |
| Todd Beaird |
Operational/Managerial Control | Jan 1, 2022 | |
| Adp of the SNF | Jan 1, 2022 | ||
| Donald B Bedell |
Operational/Managerial Control | Jul 5, 2000 | |
| Daniel Itano |
Operational/Managerial Control | Apr 1, 2025 | |
| Adp of the SNF | Apr 1, 2025 | ||
| DCB Real Estate Partnership LP |
Adp of the SNF | Jan 1, 2010 | |
| Forvis Mazars LLP |
Adp of the SNF | Aug 16, 2021 | |
| Agh1 LLC |
Operational/Managerial Control | Dec 2, 2016 | |
| Adp of the SNF | May 28, 2025 | ||
| |
Adp of the SNF | Jan 1, 2000 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050613000913 | AZ | Part a Provider - Skilled Nursing Facility | 6901840784 | Practice locations: Kingman, AZ |
National Provider Directory
Interoperability endpoints
- daniel.itano@mmdeserthighlandcc.contexture.medalliesmail.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | NCI306 | AZ | Yes |
Addresses
Primary practice location
1081 Kathleen Ave
Kingman, AZ 86401-3918
Mailing address
PO Box 1210
Sikeston, MO 63801-1210
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 633182 | Medicaid | AZ |
Other names
- Desert Highlands Care Center
Other providers in Kingman, AZ
- Kingman Healthcare, Inc
- Kingman Hometown Pharmacy LLC
- Kingman Hospital Inc
- Kingman Kidney Clinic Inc.
- Kingman Neurology
- Kingman Oncology Institute LLC
- Kingman Pulmonary Associates, LLC
- Kingman Radiology Associates LLC
- Kingman Senior Living, LLC
- Kingman Transportation Service, LLC
All providers in Kingman, AZ · Skilled Nursing Facility in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 3, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.