Basic Information
| Provider Information | |||||||||
| NPI: | 1083872790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | CELENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLADE | ||||||||
| OtherFirstName: | CELENA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5700 NW 27TH CT | ||||||||
| Address2: | BLDG D | ||||||||
| City: | LAUDERHILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333132389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544973856 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5700 NW 27TH CT | ||||||||
| Address2: | BLDG D | ||||||||
| City: | LAUDERHILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333132389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544973856 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 760669900 | 05 | FL | MEDICAID |