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General NPI Number Information
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NPI Number | 1164939849
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Entity Type | Individual
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Provider Name | JEREMY KEITH KING M.ED, LAT, ATC, ITAT
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Gender | Male
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Dates
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Enumeration Date | 01/04/2018
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Last Update Date | 01/04/2018
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Provider Practice Location Address
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Address Line | 360 REBELS CIR
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City | BLUE RIDGE
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State | GA
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Zip | 30513-8137
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Country | US
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Telephone | 706-455-5134
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Fax | 706-632-6552
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Provider Business Mailing Address
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Address Line | 184 BLACKBERRY LN
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City | MORGANTON
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State | GA
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Zip | 30560-3700
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Country | US
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Telephone | 706-455-5134
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT002001
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License Number State | GA
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