Healthcare Provider Details

I. General information

NPI: 1760323042
Provider Name (Legal Business Name): KINGDOM CARE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 CENTER ST
FULTON MO
65251-1922
US

IV. Provider business mailing address

1605 UNION AVE
BALTIMORE MD
21211-1918
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-6646
  • Fax: 573-642-2202
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: NATHAN GOLDBERG
Title or Position: MEDICARE AUTHORIZED OFFICIAL
Credential:
Phone: 443-208-1826