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General NPI Number Information
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NPI Number | 1770846800
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Entity Type | Organization
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Legal Business Name | KINGDOM CARE ASSOCIATES, LLC
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Dates
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Enumeration Date | 06/22/2012
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Last Update Date | 06/22/2021
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Provider Practice Location Address
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Address Line | 23 CARVER CIRCLE
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City | PORTSMOUTH
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State | VA
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Zip | 23701
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Country | US
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Telephone | 757-319-3662
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Fax |
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Provider Business Mailing Address
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Address Line | 1517 CARSON CRES. EAST
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City | PORTSMOUTH
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State | VA
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Zip | 23701
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Country | US
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Telephone | 757-319-3662
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Fax |
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Authorized Official
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Title or Position | LLC MEMBER/OWNER
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Name | PATRECE SCOTT
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Credential |
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Telephone | 757-319-3662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 302F001
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License Number State | VA
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