Provider Demographics
NPI:1952963159
Name:KING, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
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 1:132 S SAN ROMAN RD
Mailing Address - Street 2:
Mailing Address - City:BAYVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78566-4866
Mailing Address - Country:US
Mailing Address - Phone:956-621-6631
Mailing Address - Fax:
Practice Address - Street 1:637 E BARRA LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-1607
Practice Address - Country:US
Practice Address - Phone:956-621-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty