Healthcare Provider Details

I. General information

NPI: 1508630906
Provider Name (Legal Business Name): KINGDOM ELEMENTS MIDWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E 25TH ST
BALTIMORE MD
21218-5504
US

IV. Provider business mailing address

901 E 25TH ST
BALTIMORE MD
21218-5504
US

V. Phone/Fax

Practice location:
  • Phone: 443-793-8485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHANTIA L BEAN
Title or Position: DIRECTOR
Credential:
Phone: 443-793-8485