Provider Demographics
NPI:1144515420
Name:KINGDOM BUILDERS MINISTER, INC
Entity type:Organization
Organization Name:KINGDOM BUILDERS MINISTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GRISSELLE
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:REVEREND
Authorized Official - Phone:352-678-8554
Mailing Address - Street 1:200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-9250
Mailing Address - Country:US
Mailing Address - Phone:352-432-3704
Mailing Address - Fax:352-988-5866
Practice Address - Street 1:200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:FL
Practice Address - Zip Code:34715-9250
Practice Address - Country:US
Practice Address - Phone:352-432-3704
Practice Address - Fax:352-988-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid
FL=========Medicare Oscar/Certification
FL=========Medicare UPIN