Healthcare Provider Details

I. General information

NPI: 1043142615
Provider Name (Legal Business Name): KINGDOM HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12451 S 79TH AVE
PAPILLION NE
68046-4694
US

IV. Provider business mailing address

12451 S 79TH AVE
PAPILLION NE
68046-4694
US

V. Phone/Fax

Practice location:
  • Phone: 402-718-0538
  • Fax:
Mailing address:
  • Phone: 402-718-0538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ALONZO WYNNE
Title or Position: OWNER
Credential:
Phone: 402-718-0538