Basic Information
| Provider Information | |||||||||
| NPI: | 1811217722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KERA | ||||||||
| MiddleName: | TI VONDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 ROCKWOOD LN | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064365761 | ||||||||
| FaxNumber: | 6064365797 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 KY 15 N | ||||||||
| Address2: | |||||||||
| City: | CAMPTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066687420 | ||||||||
| FaxNumber: | 6066687404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.