Provider Demographics
NPI:1700425949
Name:KING, CHARLES GEORGE JR (LMT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GEORGE
Last Name:KING
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
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Mailing Address - Street 1:3905 N 7TH AVE UNIT 34965
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3368
Mailing Address - Country:US
Mailing Address - Phone:480-518-2090
Mailing Address - Fax:855-518-2090
Practice Address - Street 1:6223 N 20TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1516
Practice Address - Country:US
Practice Address - Phone:480-518-2090
Practice Address - Fax:855-518-2090
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZMT-09329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMT-09329OtherMASSAGE LICENSE