MEDICARE: THE KINGDOM WELLNESS GROUP

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1801754684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE KINGDOM WELLNESS GROUP

Provider Business Mailing Address
First Line	:	6148 LITTLE CREEK CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1321
Country	:	US
Telephone Number	:	313-810-2948
Fax Number	:

Provider Business Practice Location Address
First Line	:	6148 LITTLE CREEK CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1321
Country	:	US
Telephone Number	:	313-810-2948
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	DESHAWN HARRIS
Credential	:	NURSE PRACTITIONER
Telephone Number	:	313-810-2948

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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