Provider Demographics
NPI:1457898330
Name:KING OF KINGS OUTPATIENT AND PERINATAL SERVICES PROGRAM
Entity Type:Organization
Organization Name:KING OF KINGS OUTPATIENT AND PERINATAL SERVICES PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II CAS
Authorized Official - Phone:559-266-6449
Mailing Address - Street 1:2302 S MARTIN L KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-4135
Mailing Address - Country:US
Mailing Address - Phone:559-442-0400
Mailing Address - Fax:
Practice Address - Street 1:2302 S MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-4135
Practice Address - Country:US
Practice Address - Phone:559-442-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KING OF KINGS COMMUNITY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100024BN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health