Provider Demographics
NPI:1720021496
Name:KINGDOM LIVING HEALTHCARE SC
Entity Type:Organization
Organization Name:KINGDOM LIVING HEALTHCARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUCKLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-445-0292
Mailing Address - Street 1:1701 W MONTEREY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4257
Mailing Address - Country:US
Mailing Address - Phone:773-445-0292
Mailing Address - Fax:
Practice Address - Street 1:1701 W MONTEREY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4257
Practice Address - Country:US
Practice Address - Phone:773-445-0292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X, 207T00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211640Medicare ID - Type Unspecified