Provider Demographics
NPI:1891946158
Name:DR. CHRISTIAN A. KING OPTOMETRIST, LLC
Entity Type:Organization
Organization Name:DR. CHRISTIAN A. KING OPTOMETRIST, LLC
Other - Org Name:CHRISTIAN A. KING, OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-445-5436
Mailing Address - Street 1:1001 S. DEFIANCE ST.
Mailing Address - Street 2:PO BOX 38
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-0038
Mailing Address - Country:US
Mailing Address - Phone:419-445-5436
Mailing Address - Fax:419-446-4818
Practice Address - Street 1:1001 S. DEFIANCE ST.
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-0038
Practice Address - Country:US
Practice Address - Phone:419-445-5436
Practice Address - Fax:419-446-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4116T1056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0768129Medicaid
OH7769130001OtherMEDICARE