MEDICARE: DAEMON KING

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	172A00000X	Driver	RU778586	OH

General Provider Information

NPI Number	:	1548910987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAEMON KING

Provider Business Mailing Address
First Line	:	1096 E 177TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3142
Country	:	US
Telephone Number	:	216-882-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1096 E 177TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3142
Country	:	US
Telephone Number	:	216-882-9770
Fax Number	:

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

Provider Enumeration Date	:	03/28/2022
Last Update Date	:	03/28/2022

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Directions to “ DAEMON KING ” Practice Location

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