MEDICARE: KING CERTIFIED RESIDENTIAL FACILITY

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	5324343	AL

General Provider Information

NPI Number	:	1497910244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING CERTIFIED RESIDENTIAL FACILITY

Provider Business Mailing Address
First Line	:	4008 FLATWOODS RD
Second Line	:
City	:	NORTHPORT
State	:	AL
Zip	:	35473-1101
Country	:	US
Telephone Number	:	205-792-7829
Fax Number	:	205-330-1359

Provider Business Practice Location Address
First Line	:	4008 FLATWOODS ROAD
Second Line	:
City	:	NORTHPORT
State	:	AL
Zip	:	35473-1101
Country	:	US
Telephone Number	:	205-792-7829
Fax Number	:

Authorized Official
Title or Position	:	FAMILY PROVIDER
Name	:	RENEE KING HOLLEY
Credential	:
Telephone Number	:	205-792-7829

Provider Enumeration Date	:	07/22/2008
Last Update Date	:	07/22/2008

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