MEDICARE: KINGDOM WOMEN 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	310400000X	Assisted Living Facility	AL10150H	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	225857	OTHER	AZ	AHCCCS MANAGE CARE NUMBER

General Provider Information

NPI Number	:	1902330392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM WOMEN LLC

Provider Business Mailing Address
First Line	:	4941 W DESERT LN
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-7365
Country	:	US
Telephone Number	:	816-377-4224
Fax Number	:	602-687-9274

Provider Business Practice Location Address
First Line	:	8311 W FOREST GROVE AVE
Second Line	:
City	:	TOLLESON
State	:	AZ
Zip	:	85353-3628
Country	:	US
Telephone Number	:	816-377-4224
Fax Number	:	602-687-9274

Authorized Official
Title or Position	:	COOWNER
Name	:	MRS. MYRRIE HAYES
Credential	:
Telephone Number	:	816-377-4224

Provider Enumeration Date	:	04/12/2017
Last Update Date	:	04/12/2017

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Directions to “KINGDOM WOMEN LLC ” Practice Location

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