Provider Demographics
NPI:1528653557
Name:KING, KENNETH JOSEPH (LAT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:KING
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:JOSEPH
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT
Mailing Address - Street 1:8976 SCARLET CRK
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3785
Mailing Address - Country:US
Mailing Address - Phone:210-445-7489
Mailing Address - Fax:
Practice Address - Street 1:23203 BULVERDE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-2203
Practice Address - Country:US
Practice Address - Phone:210-356-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3935OtherATHLETIC TRAINER