Provider Demographics
NPI:1013523885
Name:KINGDOM EXPRESSIONS ATL LLC
Entity Type:Organization
Organization Name:KINGDOM EXPRESSIONS ATL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAKERA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-508-9023
Mailing Address - Street 1:101 W CAMPBELLTON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-1218
Mailing Address - Country:US
Mailing Address - Phone:337-508-9023
Mailing Address - Fax:
Practice Address - Street 1:101 W CAMPBELLTON ST
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-1218
Practice Address - Country:US
Practice Address - Phone:888-859-4202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management