Provider Demographics
NPI:1316228299
Name:KING, WILLIA D
Entity Type:Individual
Prefix:
First Name:WILLIA
Middle Name:D
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 1:308 E FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1729
Mailing Address - Country:US
Mailing Address - Phone:903-930-5824
Mailing Address - Fax:
Practice Address - Street 1:308 E FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1729
Practice Address - Country:US
Practice Address - Phone:903-930-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX550809477171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor