Provider Demographics
NPI:1427464288
Name:KING, BRENNON (ATC, CES)
Entity type:Individual
Prefix:
First Name:BRENNON
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 JAYCEE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1243
Mailing Address - Country:US
Mailing Address - Phone:425-248-0315
Mailing Address - Fax:
Practice Address - Street 1:610 PINAL AVE
Practice Address - Street 2:
Practice Address - City:ORCUTT
Practice Address - State:CA
Practice Address - Zip Code:93455-5302
Practice Address - Country:US
Practice Address - Phone:425-248-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000136782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer