Provider Demographics
NPI:1689264053
Name:KINGDOM HEALTH LABORATORY LLC
Entity Type:Organization
Organization Name:KINGDOM HEALTH LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-995-7795
Mailing Address - Street 1:4887 ALPHA RD STE 205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-4632
Mailing Address - Country:US
Mailing Address - Phone:469-995-7851
Mailing Address - Fax:469-995-7851
Practice Address - Street 1:4887 ALPHA RD STE 205
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-4632
Practice Address - Country:US
Practice Address - Phone:469-995-7851
Practice Address - Fax:469-995-7851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory