Provider Demographics
NPI:1295404259
Name:KIRK KING, CARRIE L
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:KIRK 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 1:1923 PERTH RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-1842
Mailing Address - Country:US
Mailing Address - Phone:440-622-7314
Mailing Address - Fax:
Practice Address - Street 1:1923 PERTH RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-1842
Practice Address - Country:US
Practice Address - Phone:440-622-7314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4303904Medicaid