Provider Demographics
NPI:1255970885
Name:KING, BRADY
Entity type:Individual
Prefix:MR
First Name:BRADY
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 CARPIN CIR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8121
Mailing Address - Country:US
Mailing Address - Phone:719-660-7104
Mailing Address - Fax:
Practice Address - Street 1:450 S CAMINO DEL RIO STE 205
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-6857
Practice Address - Country:US
Practice Address - Phone:970-247-0150
Practice Address - Fax:970-247-0150
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHAD.0000239237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist