Provider Demographics
NPI:1144481516
Name:KINGDOM MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:KINGDOM MEDICAL SUPPLY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-453-1123
Mailing Address - Street 1:1020 PARK DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30647
Mailing Address - Country:US
Mailing Address - Phone:706-453-1123
Mailing Address - Fax:706-453-1124
Practice Address - Street 1:1020 PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642
Practice Address - Country:US
Practice Address - Phone:706-453-1123
Practice Address - Fax:706-453-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies