Provider Demographics
NPI:1891063160
Name:KING, DWAYNE ANSEL (PT)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:ANSEL
Last Name:KING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 B SUNSET COURT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-2429
Mailing Address - Country:US
Mailing Address - Phone:803-796-5116
Mailing Address - Fax:803-796-5131
Practice Address - Street 1:132 B SUNSET COURT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2429
Practice Address - Country:US
Practice Address - Phone:803-796-5116
Practice Address - Fax:803-796-5131
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC65632251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic