MEDICARE: KELLY KING B.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265637763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY KING B.A.

Provider Business Mailing Address
First Line	:	11120 STRATFORD DR
Second Line	:	UNIT 127
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7239
Country	:	US
Telephone Number	:	405-264-6916
Fax Number	:

Provider Business Practice Location Address
First Line	:	4436 NW 50TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2212
Country	:	US
Telephone Number	:	405-858-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2007
Last Update Date	:	07/09/2007

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