=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811930134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCUS SHANNON KING PT ATC LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 01/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6399 GOODMAN RD SUITE 108
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-7070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-652-0413
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6399 GOODMAN RD SUITE 108
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-7070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-652-0413
-----------------------------------------------------
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 | PT2745
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT0383
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------