Healthcare Provider Details

I. General information

NPI: 1134082787
Provider Name (Legal Business Name): DEMIANNA KING H.I.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E BROADWAY STE B
COUNCIL BLUFFS IA
51503-4411
US

IV. Provider business mailing address

421 E BROADWAY ST STE. B
COUNCIL BLUFFS IA
51503
US

V. Phone/Fax

Practice location:
  • Phone: 712-323-2301
  • Fax:
Mailing address:
  • Phone: 712-323-2301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number129672
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: