Healthcare Provider Details

I. General information

NPI: 1124936612
Provider Name (Legal Business Name): KINGDOM RETREAT SALON AND MORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12680 W LAKE HOUSTON PKWY STE 500
HOUSTON TX
77044-6088
US

IV. Provider business mailing address

12680 W LAKE HOUSTON PKWY STE 500
HOUSTON TX
77044-6088
US

V. Phone/Fax

Practice location:
  • Phone: 832-850-0968
  • Fax:
Mailing address:
  • Phone: 832-850-0968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. LATRICE WILLIAMS-TOLBERT
Title or Position: CLINICAL TRICHOLOGIST
Credential: TC, HLPC,
Phone: 832-850-0968