Provider Demographics
NPI:1811457765
Name:KINGDOM'S CARE ON THE LAKE
Entity type:Organization
Organization Name:KINGDOM'S CARE ON THE LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDIANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-688-8210
Mailing Address - Street 1:25325 CHATWORTH DR
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1839
Mailing Address - Country:US
Mailing Address - Phone:216-688-8210
Mailing Address - Fax:
Practice Address - Street 1:25325 CHATWORTH DR
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1839
Practice Address - Country:US
Practice Address - Phone:216-688-8210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGDOM'S CARE ON THE LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health