Healthcare Provider Details

I. General information

NPI: 1639344781
Provider Name (Legal Business Name): BRIAN A. KING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6142 ROOSEVELT RD SUITE 105
OAK PARK IL
60304-2311
US

IV. Provider business mailing address

6142 W ROOSEVELT ROAD SUITE 105
OAK PARK IL
60304
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-0021
  • Fax: 708-848-0598
Mailing address:
  • Phone: 708-848-0021
  • Fax: 708-848-0598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BRIAN A KING
Title or Position: PODIATRIST
Credential:
Phone: 708-848-0021