MEDICARE: MR. CHARLES 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	363LF0000X	Family Nurse Practitioner	3010331	KY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3010331	KY

General Provider Information

NPI Number	:	1790134948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES KING

Provider Business Mailing Address
First Line	:	122 WHISPERING HILLS DR
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-9753
Country	:	US
Telephone Number	:	859-625-2804
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 KY 11 N
Second Line	:
City	:	BOONEVILLE
State	:	KY
Zip	:	41314-9155
Country	:	US
Telephone Number	:	606-593-6395
Fax Number	:	606-593-5916

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

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	11/02/2021

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Directions to “ MR. CHARLES KING ” Practice Location

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