Provider Demographics
NPI:1962725879
Name:KING, TRACEY LYNETTE (PT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNETTE
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 VIA DE LA VALLE
Mailing Address - Street 2:SUITE 205 AND 206
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-4247
Mailing Address - Country:US
Mailing Address - Phone:858-350-6500
Mailing Address - Fax:858-350-6505
Practice Address - Street 1:3790 VIA DE LA VALLE
Practice Address - Street 2:SUITE 205 AND 206
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-4247
Practice Address - Country:US
Practice Address - Phone:858-350-6500
Practice Address - Fax:858-350-6505
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADG892YMedicare PIN