MEDICARE: KINGDOM WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1457957722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM WELLNESS LLC

Provider Business Mailing Address
First Line	:	3909 S MARYLAND PKWY STE 408
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7526
Country	:	US
Telephone Number	:	702-485-3403
Fax Number	:

Provider Business Practice Location Address
First Line	:	3909 S MARYLAND PKWY STE 408
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7526
Country	:	US
Telephone Number	:	702-485-3403
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	EXECUTIVE DIRECTOR
Credential	:
Telephone Number	:	702-485-3403

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	01/26/2022

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Directions to “KINGDOM WELLNESS LLC ” Practice Location

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