Provider Demographics
NPI:1477677813
Name:KINGDOM HOME CARE
Entity Type:Organization
Organization Name:KINGDOM HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-353-5522
Mailing Address - Street 1:1530 EVANS ST
Mailing Address - Street 2:STE 211
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5301
Mailing Address - Country:US
Mailing Address - Phone:252-353-5522
Mailing Address - Fax:252-353-5330
Practice Address - Street 1:1530 EVANS ST
Practice Address - Street 2:STE 211
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5301
Practice Address - Country:US
Practice Address - Phone:252-353-5522
Practice Address - Fax:252-353-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3221251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601409Medicaid
NC3418063Medicaid