Provider Demographics
NPI:1821818048
Name:KING, CHAVON L
Entity type:Individual
Prefix:
First Name:CHAVON
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 RICHMOND SQ
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-2061
Mailing Address - Country:US
Mailing Address - Phone:405-658-3618
Mailing Address - Fax:
Practice Address - Street 1:4621 SE 21ST ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-4003
Practice Address - Country:US
Practice Address - Phone:405-658-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK$$$$$$$$$171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No171M00000XOther Service ProvidersCase Manager/Care Coordinator