Healthcare Provider Details

I. General information

NPI: 1063790459
Provider Name (Legal Business Name): MARTIN LUTHER KING, JR TECHNOLOGY ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 FAIRFIELD ST
SACRAMENTO CA
95815-1132
US

IV. Provider business mailing address

3051 FAIRFIELD ST
SACRAMENTO CA
95815-1132
US

V. Phone/Fax

Practice location:
  • Phone: 916-566-3490
  • Fax:
Mailing address:
  • Phone: 916-566-3490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: DANNY WILLIAMS
Title or Position: PRINCIPAL
Credential: TEACHER
Phone: 916-566-3490