MEDICARE: CORNELIUS KING

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	171W00000X	Contractor
2	171WV0202X	Vehicle Modifications Contractor

General Provider Information

NPI Number	:	1487050860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORNELIUS KING

Provider Business Mailing Address
First Line	:	6420 RICHMOND AVE
Second Line	:	577
City	:	HOUSTON
State	:	TX
Zip	:	77057-5929
Country	:	US
Telephone Number	:	281-501-0622
Fax Number	:

Provider Business Practice Location Address
First Line	:	6420 RICHMOND AVE
Second Line	:	577
City	:	HOUSTON
State	:	TX
Zip	:	77057-5929
Country	:	US
Telephone Number	:	281-501-0622
Fax Number	:

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

Provider Enumeration Date	:	11/12/2014
Last Update Date	:	11/12/2014

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Directions to “ CORNELIUS KING ” Practice Location

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