Healthcare Provider Details

I. General information

NPI: 1063837524
Provider Name (Legal Business Name): BOBBY KING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 46TH ST.
OKLAHOMA CITY OK
73108
US

IV. Provider business mailing address

401 46TH ST.
OKLAHOMA CITY OK
73108
US

V. Phone/Fax

Practice location:
  • Phone: 405-602-6331
  • Fax:
Mailing address:
  • Phone: 405-602-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: