Kingdom Healthcare Services, LLC

Primary specialty

Primary Care Clinic/CenterTaxonomy code 261QP2300X

Legal business name

KINGDOM HEALTHCARE SERVICES, LLC

Practice address

4095 Atlanta Hwy
Hiram, GA 30141-1854

Phone

(404) 488-9521

NPI assigned

Feb 11, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lucille M Travis, NPNPI 1093206674

Title

Ceo

Phone

(678) 978-4947

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Lucille Travis, NP

  • Primary Care Nurse Practitioner
  • Hiram, GA
  • NPI 1093206674
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1581379200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1697932800000",
    "number": "1750913349",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4095 ATLANTA HWY",
            "city": "HIRAM",
            "state": "GA",
            "postal_code": "301411854",
            "telephone_number": "404-488-9521"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4095 ATLANTA HWY",
            "city": "HIRAM",
            "state": "GA",
            "postal_code": "301411854",
            "telephone_number": "404-488-9521"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "215 Palisades Dr",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "GA",
            "postal_code": "301570928",
            "country_code": "US",
            "telephone_number": "678-978-4947",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "KINGDOM HEALTHCARE SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-02-11",
        "last_updated": "2023-10-22",
        "certification_date": "2023-10-22",
        "status": "A",
        "authorized_official_last_name": "TRAVIS",
        "authorized_official_first_name": "LUCILLE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-978-4947",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "251J00000X",
            "taxonomy_group": "",
            "desc": "Nursing Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Primary Care Clinic/Center in Hiram, GA
• Providers in Hiram, GA by specialty
• Primary Care Clinic/Center in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.