=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649537523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CINDY KING L.M.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 03/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 W CLINTON ST
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31032-5322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-550-2217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1707
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31032-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-550-2217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT # 002120
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------