Basic Information
| Provider Information | |||||||||
| NPI: | 1396727624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEN B KING A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIABETES CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1260 S MAIN ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939012288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317699355 | ||||||||
| FaxNumber: | 8317544955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 S MAIN ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939012288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317699355 | ||||||||
| FaxNumber: | 8317544955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8317699355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | ZZZ65061Z | 01 | CA | BLUE SHIELD GROUP # | OTHER |