Healthcare Provider Details

I. General information

NPI: 1235103391
Provider Name (Legal Business Name): HAROLD DWAYNE KING A.T.C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 FALCON PKWY
FLOWERY BRANCH GA
30542-3176
US

IV. Provider business mailing address

4400 FALCON PKWY
FLOWERY BRANCH GA
30542-3176
US

V. Phone/Fax

Practice location:
  • Phone: 770-965-2754
  • Fax: 770-965-2616
Mailing address:
  • Phone: 770-965-2754
  • Fax: 770-965-2616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: