Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 0104556076 | VA |
NPI | 1568401818 |
---|---|
Provider Name | Dr. Keith Michael King |
First Address | Luray, VA 22835-1012 |
Second Address | Luray, VA 22835-1902 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
116154 | ANTHEM BC BS (01) | VA |