Provider Demographics
NPI:1457012585
Name:KINGDOM MEDICAL GROUP
Entity Type:Organization
Organization Name:KINGDOM MEDICAL GROUP
Other - Org Name:KINGDOM CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-434-1045
Mailing Address - Street 1:501 S FALKENBURG RD STE C23
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-8058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 S FALKENBURG RD STE C23
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-8058
Practice Address - Country:US
Practice Address - Phone:813-434-1045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty