=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801007802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KING OF KINGS COMMUNITY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2302 S MARTIN L KING JR BLVD
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93706-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-442-0400
-----------------------------------------------------
Fax | 559-442-0401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2302 S MARTIN L KING JR BLVD
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93706-4135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-442-0400
-----------------------------------------------------
Fax | 559-442-0401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ROBERT SINGLETON
-----------------------------------------------------
Credential | CAS I
-----------------------------------------------------
Telephone | 559-442-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 100024BN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 100024BN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------