Provider Demographics
NPI:1336620632
Name:KING, RANDELL ROSHAUN (PTA)
Entity Type:Individual
Prefix:
First Name:RANDELL
Middle Name:ROSHAUN
Last Name:KING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:RANDELL
Other - Middle Name:ROSHAUN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:410 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-6286
Mailing Address - Country:US
Mailing Address - Phone:903-316-3253
Mailing Address - Fax:
Practice Address - Street 1:508 PIERCE ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-3335
Practice Address - Country:US
Practice Address - Phone:903-881-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2059006225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant