Provider Demographics
NPI:1649487323
Name:KING, MATTHEW LEE (CHHA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LEE
Last Name:KING
Suffix:
Gender:M
Credentials:CHHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10287 CROUSE WILLISON RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-9109
Mailing Address - Country:US
Mailing Address - Phone:740-967-0762
Mailing Address - Fax:
Practice Address - Street 1:10287 CROUSE WILLISON RD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-9109
Practice Address - Country:US
Practice Address - Phone:740-967-0762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2098662Medicaid