Provider Demographics
NPI:1659568905
Name:KING, ROOSEVELT JR
Entity Type:Individual
Prefix:MR
First Name:ROOSEVELT
Middle Name:
Last Name:KING
Suffix:JR
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 1:2923 GLADIOLUS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75233-3905
Mailing Address - Country:US
Mailing Address - Phone:214-808-2608
Mailing Address - Fax:214-331-3086
Practice Address - Street 1:2923 GLADIOLUS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75233-3905
Practice Address - Country:US
Practice Address - Phone:214-808-2608
Practice Address - Fax:214-331-3086
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119896310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility