MEDICARE: FREDERICK DOUGLAS KING II PHD PT

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	225100000X	Physical Therapist	PT005390	CA

General Provider Information

NPI Number	:	1821083676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK DOUGLAS KING II PHD PT

Provider Business Mailing Address
First Line	:	2486 N PONDEROSA DR
Second Line	:	STE D106
City	:	CAMARILLO
State	:	CA
Zip	:	93010-2376
Country	:	US
Telephone Number	:	805-484-5447
Fax Number	:	805-484-2158

Provider Business Practice Location Address
First Line	:	2486 N PONDEROSA DR
Second Line	:	STE D106
City	:	CAMARILLO
State	:	CA
Zip	:	93010-2376
Country	:	US
Telephone Number	:	805-484-5447
Fax Number	:	805-484-2158

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

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	07/08/2007

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