Provider Demographics
NPI:1902569023
Name:LORIQUEN HOLDINGS DBA KINKISTRY
Entity Type:Organization
Organization Name:LORIQUEN HOLDINGS DBA KINKISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-416-3818
Mailing Address - Street 1:5623 VININGS PLACE TRL
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5681
Mailing Address - Country:US
Mailing Address - Phone:404-416-3818
Mailing Address - Fax:
Practice Address - Street 1:5623 VININGS PLACE TRL
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5681
Practice Address - Country:US
Practice Address - Phone:404-416-3818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LORIQUEN HOLDINGS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA123456OtherCAQH