Provider Demographics
NPI:1508598558
Name:KING, EDWIN S (LE)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:S
Last Name:KING
Suffix:
Gender:M
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 PARK LAKE CT
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9491
Mailing Address - Country:US
Mailing Address - Phone:916-524-3285
Mailing Address - Fax:530-820-3992
Practice Address - Street 1:1160 PARK LAKE CT
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:CA
Practice Address - Zip Code:95658-9491
Practice Address - Country:US
Practice Address - Phone:916-524-3285
Practice Address - Fax:530-820-3992
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9762171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty