Provider Demographics
NPI:1255578043
Name:KING, LAVERNE (RT (R)(M))
Entity type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:RT (R)(M)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2198
Mailing Address - Fax:928-283-1312
Practice Address - Street 1:167 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2198
Practice Address - Fax:928-283-1312
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14515247100000X
AZ27772471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist