Healthcare Provider Details

I. General information

NPI: 1427464288
Provider Name (Legal Business Name): BRENNON KING ATC, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PINAL AVE
ORCUTT CA
93455-5302
US

IV. Provider business mailing address

339 JAYCEE DR
SAN LUIS OBISPO CA
93405-1243
US

V. Phone/Fax

Practice location:
  • Phone: 425-248-0315
  • Fax:
Mailing address:
  • Phone: 425-248-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000013678
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: