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General NPI Number Information
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NPI Number | 1659606895
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Entity Type | Organization
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Legal Business Name | KINGDOM LIVING OUTREACH SERVICES, INC
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Dates
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Enumeration Date | 10/06/2009
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Last Update Date | 10/06/2009
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Provider Practice Location Address
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Address Line | 20303 CRAWFORD AVE SUITE 100
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1073
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Country | US
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Telephone | 708-747-9399
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Fax | 708-747-1908
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Provider Business Mailing Address
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Address Line | 20303 CRAWFORD AVE STE 100 P.O.BOX 1213, MATTESON, IL 60443
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1173
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Country | US
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Telephone | 708-747-9399
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Fax | 708-747-1908
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. DORIS PALMER
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Credential |
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Telephone | 708-747-9399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | A-5777-0001-A
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License Number State | IL
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