Provider Demographics
NPI:1073835609
Name:KING, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:40 EASTERN AVE
Mailing Address - Street 2:C/O JENNIFER KELLEY
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5014
Mailing Address - Country:US
Mailing Address - Phone:800-760-5196
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:SACRED HEART MEDICAL CENTER
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:541-686-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist