Provider Demographics
NPI:1538431275
Name:KING, SHANNON (LAC, LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 ROUTE 111
Mailing Address - Street 2:SUITE LL8
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4756
Mailing Address - Country:US
Mailing Address - Phone:631-257-5757
Mailing Address - Fax:631-419-8057
Practice Address - Street 1:363 ROUTE 111
Practice Address - Street 2:SUITE LL8
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4756
Practice Address - Country:US
Practice Address - Phone:631-257-5757
Practice Address - Fax:631-419-8057
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025155-1172M00000X
NY005430171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist