Basic Information
| Provider Information | |||||||||
| NPI: | 1558689109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASILA-KING | ||||||||
| FirstName: | GLADYS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | SPRING BROOK TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184446232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708778620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 E END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708243521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN004153 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.