Basic Information
| Provider Information | |||||||||
| NPI: | 1932155066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KING I LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 W MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606444040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732611200 | ||||||||
| FaxNumber: | 7732611212 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 W MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606444040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732611200 | ||||||||
| FaxNumber: | 7732611212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | GARTRELL | ||||||||
| AuthorizedOfficialMiddleName: | DAVE W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7732611200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.