Provider Demographics
NPI:1023249505
Name:KINGSBROOK HEALTHCARE SERVICES PLLC
Entity type:Organization
Organization Name:KINGSBROOK HEALTHCARE SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEMITAYO
Authorized Official - Middle Name:I
Authorized Official - Last Name:SODIMU
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:214-272-9008
Mailing Address - Street 1:4600 MARK IV PKWY UNIT 162254
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-5252
Mailing Address - Country:US
Mailing Address - Phone:214-272-9008
Mailing Address - Fax:682-228-6994
Practice Address - Street 1:1230 RIVER BEND DR STE 107
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4916
Practice Address - Country:US
Practice Address - Phone:214-272-9008
Practice Address - Fax:682-228-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service