Provider Demographics
NPI:1659764330
Name:KINGHAVEN MEDICAL SYSTEM INC
Entity Type:Organization
Organization Name:KINGHAVEN MEDICAL SYSTEM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLAGUNDOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-457-3200
Mailing Address - Street 1:6335 GULFTON ST STE 103
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-1112
Mailing Address - Country:US
Mailing Address - Phone:713-457-3200
Mailing Address - Fax:
Practice Address - Street 1:6335 GULFTON ST STE 103
Practice Address - Street 2:SUITE 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-1112
Practice Address - Country:US
Practice Address - Phone:713-457-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3585879-01Medicaid
TX3585879-01Medicaid