Provider Demographics
NPI:1932564838
Name:KINGS & QUEENS LLC
Entity Type:Organization
Organization Name:KINGS & QUEENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DON
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAMEEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:731-343-8684
Mailing Address - Street 1:124 CHESTER LEVEE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7562
Mailing Address - Country:US
Mailing Address - Phone:731-343-8684
Mailing Address - Fax:
Practice Address - Street 1:118 DEVONSHIRE SQ
Practice Address - Street 2:SUITE 7
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2255
Practice Address - Country:US
Practice Address - Phone:731-343-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-18
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN212116251B00000X
TN83001251J00000X
TN17750253Z00000X, 385H00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020832Medicaid