Provider Demographics
NPI:1659606895
Name:KINGDOM LIVING OUTREACH SERVICES, INC
Entity Type:Organization
Organization Name:KINGDOM LIVING OUTREACH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-9399
Mailing Address - Street 1:20303 CRAWFORD AVE STE 100
Mailing Address - Street 2:P.O.BOX 1213, MATTESON, IL 60443
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1173
Mailing Address - Country:US
Mailing Address - Phone:708-747-9399
Mailing Address - Fax:708-747-1908
Practice Address - Street 1:20303 CRAWFORD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1073
Practice Address - Country:US
Practice Address - Phone:708-747-9399
Practice Address - Fax:708-747-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-5777-0001-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health