=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457166605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARE KINGDOM HEALTH SYSTEM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 SUNBEAM DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-388-1611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 SUNBEAM DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-388-1611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. TYESHA DEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-388-1611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------