Provider Demographics
NPI:1164892741
Name:KING, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6126
Mailing Address - Country:US
Mailing Address - Phone:207-622-5357
Mailing Address - Fax:207-622-5359
Practice Address - Street 1:226 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6126
Practice Address - Country:US
Practice Address - Phone:207-622-5357
Practice Address - Fax:207-622-5359
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDL366237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist