Provider Demographics
NPI:1477916450
Name:KING, JACK D III
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:KING
Suffix:III
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 1:440 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1151
Mailing Address - Country:US
Mailing Address - Phone:810-937-9353
Mailing Address - Fax:
Practice Address - Street 1:440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-1151
Practice Address - Country:US
Practice Address - Phone:810-937-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other