Provider Demographics
NPI:1720408255
Name:KING'S PRIMARY CARE & WELLNESS
Entity Type:Organization
Organization Name:KING'S PRIMARY CARE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:678-398-1360
Mailing Address - Street 1:4760 AUSTELL RD
Mailing Address - Street 2:5
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2007
Mailing Address - Country:US
Mailing Address - Phone:678-398-1360
Mailing Address - Fax:678-398-1362
Practice Address - Street 1:4760 AUSTELL RD
Practice Address - Street 2:5
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-2007
Practice Address - Country:US
Practice Address - Phone:678-398-1360
Practice Address - Fax:678-398-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care