Provider Demographics
NPI:1750913349
Name:KINGDOM HEALTHCARE SERVICES, LLC
Entity type:Organization
Organization Name:KINGDOM HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-978-4947
Mailing Address - Street 1:4095 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1854
Mailing Address - Country:US
Mailing Address - Phone:404-488-9521
Mailing Address - Fax:
Practice Address - Street 1:4095 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1854
Practice Address - Country:US
Practice Address - Phone:404-488-9521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility