MEDICARE: KATHY L. KING R.D.N.

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	133V00000X	Registered Dietitian	DT01751	TX

General Provider Information

NPI Number	:	1689083859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY L. KING R.D.N.

Provider Business Mailing Address
First Line	:	PO BOX 2105
Second Line	:
City	:	LAKE DALLAS
State	:	TX
Zip	:	75065-2105
Country	:	US
Telephone Number	:	940-395-3388
Fax Number	:	940-497-2927

Provider Business Practice Location Address
First Line	:	213 MAIN ST
Second Line	:
City	:	LAKE DALLAS
State	:	TX
Zip	:	75065-2721
Country	:	US
Telephone Number	:	940-497-3558
Fax Number	:	940-497-2927

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

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	08/12/2014

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