Provider Demographics
NPI:1083872790
Name:KING, CELENA
Entity Type:Individual
Prefix:
First Name:CELENA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CELENA
Other - Middle Name:
Other - Last Name:BLADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5700 NW 27TH CT
Mailing Address - Street 2:BLDG D
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2389
Mailing Address - Country:US
Mailing Address - Phone:954-497-3856
Mailing Address - Fax:
Practice Address - Street 1:5700 NW 27TH CT
Practice Address - Street 2:BLDG D
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-2389
Practice Address - Country:US
Practice Address - Phone:954-497-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760669900Medicaid