Provider Demographics
NPI:1003101700
Name:KINGDOM CLASS PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:KINGDOM CLASS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAENIKQUE
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, TDPT
Authorized Official - Phone:979-235-9640
Mailing Address - Street 1:1610 VILLLAGE TOWNHOME DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504
Mailing Address - Country:US
Mailing Address - Phone:979-235-9640
Mailing Address - Fax:
Practice Address - Street 1:1610 VILLLAGE TOWNHOME DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504
Practice Address - Country:US
Practice Address - Phone:979-235-9640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGDOM CLASS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care