Provider Demographics
NPI:1699243360
Name:KING, PHILANZO
Entity type:Individual
Prefix:
First Name:PHILANZO
Middle Name:
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 1:55 DAVIDSON ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3001
Mailing Address - Country:US
Mailing Address - Phone:619-767-8160
Mailing Address - Fax:
Practice Address - Street 1:7227 BROADWAY STE 302
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1505
Practice Address - Country:US
Practice Address - Phone:619-767-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist