Provider Demographics
NPI:1083020069
Name:KING, ANTAWAIN TAVARIO (QBA)
Entity Type:Individual
Prefix:
First Name:ANTAWAIN
Middle Name:TAVARIO
Last Name:KING
Suffix:
Gender:M
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5370 E CRAIG RD
Mailing Address - Street 2:2299
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-2100
Mailing Address - Country:US
Mailing Address - Phone:702-762-1208
Mailing Address - Fax:
Practice Address - Street 1:5370 E CRAIG RD
Practice Address - Street 2:2299
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-2100
Practice Address - Country:US
Practice Address - Phone:702-762-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor