Provider Demographics
NPI:1194401877
Name:KING, DERRICK L
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:L
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 KAREN CT # 3
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1637
Mailing Address - Country:US
Mailing Address - Phone:248-805-6859
Mailing Address - Fax:
Practice Address - Street 1:58 KAREN CT # 3
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1637
Practice Address - Country:US
Practice Address - Phone:248-805-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider