Provider Demographics
NPI:1992099873
Name:KINGDOM DOMINION LLC
Entity type:Organization
Organization Name:KINGDOM DOMINION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-525-4345
Mailing Address - Street 1:633 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2019
Mailing Address - Country:US
Mailing Address - Phone:804-525-4345
Mailing Address - Fax:804-562-7752
Practice Address - Street 1:633 NEWTON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2019
Practice Address - Country:US
Practice Address - Phone:804-525-4345
Practice Address - Fax:804-562-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA905-02-014251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health