Healthcare Provider Details

I. General information

NPI: 1629251376
Provider Name (Legal Business Name): JAMES D KING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 INDIAN WELLS RD
ALAMOGORDO NM
88310-4611
US

IV. Provider business mailing address

209 S MAIN ST
POPLAR BLUFF MO
63901-5831
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax: 573-686-2139
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR28228
License Number StateNM

VIII. Authorized Official

Name: JAMES D KING
Title or Position: PRESIDENT
Credential: CRNA
Phone: 573-686-5550