Provider Demographics
NPI:1164675385
Name:KINGDOM DOMINION LLC
Entity Type:Organization
Organization Name:KINGDOM DOMINION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-525-4345
Mailing Address - Street 1:7024 O MALLEY DR.
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234
Mailing Address - Country:US
Mailing Address - Phone:804-525-4345
Mailing Address - Fax:
Practice Address - Street 1:7024 O MALLEY DR
Practice Address - Street 2:SAME
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234
Practice Address - Country:US
Practice Address - Phone:804-525-4345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS1895533320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities