Provider Demographics
NPI:1497910244
Name:KING CERTIFIED RESIDENTIAL FACILITY
Entity Type:Organization
Organization Name:KING CERTIFIED RESIDENTIAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:KING
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-792-7829
Mailing Address - Street 1:4008 FLATWOODS RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-1101
Mailing Address - Country:US
Mailing Address - Phone:205-792-7829
Mailing Address - Fax:205-330-1359
Practice Address - Street 1:4008 FLATWOODS ROAD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-1101
Practice Address - Country:US
Practice Address - Phone:205-792-7829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5324343320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities