Healthcare Provider Details

I. General information

NPI: 1013238740
Provider Name (Legal Business Name): KINGDOM BUILDING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 WILLOW RUN ST SUITE A
MINNEOLA FL
34715
US

IV. Provider business mailing address

833 WILLOW RUN ST SUITE A
MINNEOLA FL
34715-5768
US

V. Phone/Fax

Practice location:
  • Phone: 352-678-8554
  • Fax:
Mailing address:
  • Phone: 407-347-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: GRISSELLE IVETTE SIMPSON
Title or Position: OWNER
Credential: REV
Phone: 352-678-8554