Healthcare Provider Details

I. General information

NPI: 1023576964
Provider Name (Legal Business Name): KINGDOM GIRLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W ESPLANADE AVE
KENNER LA
70065-2845
US

IV. Provider business mailing address

PO BOX 10102
NEW ORLEANS LA
70181-0102
US

V. Phone/Fax

Practice location:
  • Phone: 985-250-0385
  • Fax:
Mailing address:
  • Phone: 504-577-8791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DERRICKA MARIE GRIFFIN
Title or Position: PRESIDENT
Credential:
Phone: 504-577-8791