Healthcare Provider Details

I. General information

NPI: 1831540202
Provider Name (Legal Business Name): KINGDOM HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12816 ROBERTS ISLAND RD
ORLANDO FL
32832-6432
US

IV. Provider business mailing address

12816 ROBERTS ISLAND RD
ORLANDO FL
32832-6432
US

V. Phone/Fax

Practice location:
  • Phone: 407-440-3004
  • Fax: 407-429-3899
Mailing address:
  • Phone: 407-440-3004
  • Fax: 407-429-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME97080
License Number StateFL

VIII. Authorized Official

Name: SYED I ALI
Title or Position: PRINCIPAL / OWNER
Credential: M.D.
Phone: 909-245-8351