MEDICARE: DR. CHARLES E KING JR. D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	164497	OTHER		BC/BS OF MISSOURI
2	06032044	OTHER		BC/BS OF ILLINOIS

General Provider Information

NPI Number	:	1285733360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES E KING JR. D.C.

Provider Business Mailing Address
First Line	:	PO BOX 1343
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-1343
Country	:	US
Telephone Number	:	618-452-1986
Fax Number	:	618-452-6814

Provider Business Practice Location Address
First Line	:	1525 JOHNSON RD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-3831
Country	:	US
Telephone Number	:	618-452-1986
Fax Number	:	618-452-6814

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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