MEDICARE: KINGDOM HEALTHCARE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1750913349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM HEALTHCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	4095 ATLANTA HWY
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-1854
Country	:	US
Telephone Number	:	404-488-9521
Fax Number	:

Provider Business Practice Location Address
First Line	:	4095 ATLANTA HWY
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-1854
Country	:	US
Telephone Number	:	404-488-9521
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LUCILLE M TRAVIS
Credential	:	NP
Telephone Number	:	678-978-4947

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	10/22/2023

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