Provider Demographics
NPI:1215535083
Name:KING, REGINA
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 YOKUM ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3353
Mailing Address - Country:US
Mailing Address - Phone:304-636-3232
Mailing Address - Fax:304-636-9243
Practice Address - Street 1:725 YOKUM ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3353
Practice Address - Country:US
Practice Address - Phone:304-636-3232
Practice Address - Fax:304-636-9243
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1639237837Medicaid