Provider Demographics
NPI:1760992333
Name:KING, CHARITY
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 N EL DORADO PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4607
Mailing Address - Country:US
Mailing Address - Phone:520-748-7108
Mailing Address - Fax:
Practice Address - Street 1:7502 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6006
Practice Address - Country:US
Practice Address - Phone:520-971-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
AZ7633247385HR2055X, 171W00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ316707Medicaid