Healthcare Provider Details

I. General information

NPI: 1316125081
Provider Name (Legal Business Name): AUBREY KING ,MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 N MOUNTAIN AVE 201
UPLAND CA
91786-5073
US

IV. Provider business mailing address

545 N MOUNTAIN AVE 201
UPLAND CA
91786-5073
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-0707
  • Fax: 909-946-1946
Mailing address:
  • Phone: 909-946-0707
  • Fax: 909-946-1946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberG56023
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberG56023
License Number StateCA

VIII. Authorized Official

Name: DR. AUBREY ANCIL KING
Title or Position: CFO/ MEDICAL DIRECTOR
Credential: M.D.
Phone: 909-946-0707