Healthcare Provider Details

I. General information

NPI: 1083884803
Provider Name (Legal Business Name): RICHARD W KING JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 WINDY HILL RD SE SUITE 110
MARIETTA GA
30067-8665
US

IV. Provider business mailing address

2550 WINDY HILL RD SE SUITE 110
MARIETTA GA
30067-8665
US

V. Phone/Fax

Practice location:
  • Phone: 678-303-3200
  • Fax: 678-303-3205
Mailing address:
  • Phone: 678-303-3200
  • Fax: 678-303-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberGA021872
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number021872
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number31517
License Number StateGA

VIII. Authorized Official

Name: MRS. REITA KING
Title or Position: PART OWNER
Credential:
Phone: 678-303-3200