Provider Demographics
NPI:1962281196
Name:KING III, ALAN GREGORY
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:GREGORY
Last Name:KING III
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 1:92 OLIVIA ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1767
Mailing Address - Country:US
Mailing Address - Phone:475-414-9454
Mailing Address - Fax:
Practice Address - Street 1:92 OLIVIA ST APT 1
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1767
Practice Address - Country:US
Practice Address - Phone:475-414-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002292376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker