Provider Demographics
NPI:1659581171
Name:KING, KEVIN JAY (PTA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAY
Last Name:KING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 MOORLAND CT
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3311
Mailing Address - Country:US
Mailing Address - Phone:407-774-1610
Mailing Address - Fax:
Practice Address - Street 1:1525 HAVEN DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7566
Practice Address - Country:US
Practice Address - Phone:407-706-1270
Practice Address - Fax:407-706-1271
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18368225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant