Basic Information
Provider Information | |||||||||
NPI: | 1760992333 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | CHARITY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1161 N EL DORADO PL | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857154607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207487108 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7502 E 33RD ST | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857106006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5209715825 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2017 | ||||||||
LastUpdateDate: | 12/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385HR2055X |   | AZ | N |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 385HR2055X | 7633247 | AZ | N |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 253J00000X |   |   | Y |   | Agencies | Foster Care Agency |   | 171W00000X | 7633247 | AZ | N |   | Other Service Providers | Contractor |   |
ID Information
ID | Type | State | Issuer | Description | 316707 | 05 | AZ |   | MEDICAID |