Provider Demographics
NPI:1366116519
Name:KING, MICHAEL ROSS (LPN, NBC-HWC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROSS
Last Name:KING
Suffix:
Gender:M
Credentials:LPN, NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 N ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-3632
Mailing Address - Country:US
Mailing Address - Phone:321-412-7645
Mailing Address - Fax:
Practice Address - Street 1:1315 N ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-3632
Practice Address - Country:US
Practice Address - Phone:321-412-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA-3404531171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach