Provider Demographics
NPI:1174071914
Name:KING--HARRIS, MEDINA
Entity type:Individual
Prefix:
First Name:MEDINA
Middle Name:
Last Name:KING--HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 341
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-0341
Mailing Address - Country:US
Mailing Address - Phone:229-630-2241
Mailing Address - Fax:
Practice Address - Street 1:101 WYOMING ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-5214
Practice Address - Country:US
Practice Address - Phone:229-630-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator