Provider Demographics
NPI:1194861013
Name:KING GROUP HOME
Entity Type:Organization
Organization Name:KING GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:775-677-1114
Mailing Address - Street 1:7894 TREASURE COVE CT.
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506
Mailing Address - Country:US
Mailing Address - Phone:775-677-1114
Mailing Address - Fax:775-677-1116
Practice Address - Street 1:7894 TREASURE COVE CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-2186
Practice Address - Country:US
Practice Address - Phone:775-677-1114
Practice Address - Fax:775-677-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVGF-465264320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities