=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750587465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON BRIAN KING MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25825 VERMONT AVE
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-257-5281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6708 LOS VERDES DR APT 13
-----------------------------------------------------
City | RANCHO PALOS VERDES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90275-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-339-9560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 26934
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------