Provider Demographics
NPI:1790803203
Name:KING, TRACY OGDEN (BC HIS)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:OGDEN
Last Name:KING
Suffix:
Gender:M
Credentials:BC HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UVALDE
Mailing Address - State:TX
Mailing Address - Zip Code:78801-4852
Mailing Address - Country:US
Mailing Address - Phone:830-278-8500
Mailing Address - Fax:830-278-4084
Practice Address - Street 1:2018 E MAIN ST
Practice Address - Street 2:
Practice Address - City:UVALDE
Practice Address - State:TX
Practice Address - Zip Code:78801-4852
Practice Address - Country:US
Practice Address - Phone:830-278-8500
Practice Address - Fax:830-278-4084
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50407237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0222210102Medicaid