Provider Demographics
NPI:1790471811
Name:KING, MYRON JEREL (AUTHORIZED AGENT)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:JEREL
Last Name:KING
Suffix:
Gender:M
Credentials:AUTHORIZED AGENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S ORANGE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3411
Mailing Address - Country:US
Mailing Address - Phone:407-209-5260
Mailing Address - Fax:
Practice Address - Street 1:3876 BECONTREE PL
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:689-209-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage