Provider Demographics
NPI:1164939849
Name:KING, JEREMY KEITH (MED, LAT, ATC, ITAT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
Last Name:KING
Suffix:
Gender:M
Credentials:MED, LAT, ATC, ITAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BLACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30560-3700
Mailing Address - Country:US
Mailing Address - Phone:706-455-5134
Mailing Address - Fax:
Practice Address - Street 1:360 REBELS CIR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-8137
Practice Address - Country:US
Practice Address - Phone:706-455-5134
Practice Address - Fax:706-632-6552
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0020012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10001136OtherNATION ATHLETIC TRAINERS' ASSOCIATION MEMBER NUMBER