Provider Demographics
NPI:1225344773
Name:KING, BRENT DUANE
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DUANE
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 1:12884 S 600 W
Mailing Address - Street 2:
Mailing Address - City:HANNA
Mailing Address - State:IN
Mailing Address - Zip Code:46340-9788
Mailing Address - Country:US
Mailing Address - Phone:219-405-8509
Mailing Address - Fax:219-733-2561
Practice Address - Street 1:12884 S 600 W
Practice Address - Street 2:
Practice Address - City:HANNA
Practice Address - State:IN
Practice Address - Zip Code:46340-9788
Practice Address - Country:US
Practice Address - Phone:219-405-8509
Practice Address - Fax:219-733-2561
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8960520176171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications