1144488594 NPI number — KINGDOMWAY MEDICAL INC

Table of content: (NPI 1144488594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144488594 NPI number — KINGDOMWAY MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGDOMWAY MEDICAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KINGDOMWAY MEDICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144488594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 TIVOLI GARDENS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-1528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-742-0436
Provider Business Mailing Address Fax Number:
770-742-0356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 TIVOLI GARDENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-742-0436
Provider Business Practice Location Address Fax Number:
770-742-0356
Provider Enumeration Date:
06/01/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SEAY
Authorized Official First Name:
HAZEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
770-742-0436

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)