Provider Demographics
NPI:1770846800
Name:KINGDOM CARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:KINGDOM CARE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRECE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-319-3662
Mailing Address - Street 1:1517 CARSON CRES. EAST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701
Mailing Address - Country:US
Mailing Address - Phone:757-319-3662
Mailing Address - Fax:
Practice Address - Street 1:23 CARVER CIRCLE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701
Practice Address - Country:US
Practice Address - Phone:757-319-3662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA302F001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization