Provider Demographics
NPI:1144333089
Name:KINGDOM MEDICAL EQUIPMENT LLC
Entity type:Organization
Organization Name:KINGDOM MEDICAL EQUIPMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-355-1511
Mailing Address - Street 1:1834 NW 52ND ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3122
Mailing Address - Country:US
Mailing Address - Phone:580-355-1511
Mailing Address - Fax:580-355-0455
Practice Address - Street 1:1824 NW 52ND ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3122
Practice Address - Country:US
Practice Address - Phone:580-355-1511
Practice Address - Fax:580-355-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073650 AMedicaid
OK200073650 BMedicaid
OK=========001OtherBLUECROSS BLUESHIELD OK
OK200073650 AMedicaid
OK=========OtherTRICARE
OK200073650 BMedicaid