Basic Information
Provider Information | |||||||||
NPI: | 1124158761 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUDIOLOGIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26222 RR 12 | ||||||||
Address2: |   | ||||||||
City: | DRIPPING SPRINGS | ||||||||
State: | TX | ||||||||
PostalCode: | 786204903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128580300 | ||||||||
FaxNumber: | 5128582714 | ||||||||
Practice Location | |||||||||
Address1: | 3270 SHERWOOD WAY | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769013564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3259499993 | ||||||||
FaxNumber: | 3259470277 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2007 | ||||||||
LastUpdateDate: | 11/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 50303 | TX | N |   | Speech, Language and Hearing Service Providers | Audiologist |   | 237700000X | 50303 | TX | N |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   | 237600000X | 50303 | TX | Y |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
ID Information
ID | Type | State | Issuer | Description | 178190801 | 05 | TX |   | MEDICAID |