Healthcare Provider Details

I. General information

NPI: 1114484136
Provider Name (Legal Business Name): KINGDOM CARE LIVING HOMEMAKER AND COMPANION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 MOSSWOOD CHASE ST
ORANGE PARK FL
32065-5541
US

IV. Provider business mailing address

823 MOSSWOOD CHASE ST
ORANGE PARK FL
32065-5541
US

V. Phone/Fax

Practice location:
  • Phone: 954-464-5784
  • Fax:
Mailing address:
  • Phone: 954-464-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. NAKITIA JACKSON
Title or Position: CEO/ADMINISTRATOR
Credential: APRN-BC
Phone: 954-464-5784