Healthcare Provider Details

I. General information

NPI: 1457012585
Provider Name (Legal Business Name): KINGDOM MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S FALKENBURG RD STE A2
TAMPA FL
33619-8040
US

IV. Provider business mailing address

501 S FALKENBURG RD STE A2
TAMPA FL
33619-8040
US

V. Phone/Fax

Practice location:
  • Phone: 813-434-1045
  • Fax: 813-434-1259
Mailing address:
  • Phone: 813-434-1045
  • Fax: 813-434-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. FREDRICK THOMAS WILLIAMS
Title or Position: CEO
Credential:
Phone: 813-434-1045