Provider Demographics
NPI:1457957722
Name:KINGDOM WELLNESS LLC
Entity Type:Organization
Organization Name:KINGDOM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EXECUTIVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-485-3403
Mailing Address - Street 1:3909 S MARYLAND PKWY STE 408
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7526
Mailing Address - Country:US
Mailing Address - Phone:702-485-3403
Mailing Address - Fax:
Practice Address - Street 1:3909 S MARYLAND PKWY STE 408
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7526
Practice Address - Country:US
Practice Address - Phone:702-485-3403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty