Basic Information
| Provider Information | |||||||||
| NPI: | 1609847433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | HELEN | ||||||||
| MiddleName: | JELKS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1480 TIMBERLANE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323121713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508934005 | ||||||||
| FaxNumber: | 8508939987 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323513137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506279521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OP1888 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0782904 | 05 | FL | MEDICAID |