Provider Demographics
NPI:1770872400
Name:KING, SAMANTHA LEA (PT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEA
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-8431
Mailing Address - Country:US
Mailing Address - Phone:478-783-4460
Mailing Address - Fax:478-783-4466
Practice Address - Street 1:1013 MAIN ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3353
Practice Address - Country:US
Practice Address - Phone:478-783-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist