Provider Demographics
NPI:1689412082
Name:KING, TEQUILA (PTA)
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4411
Mailing Address - Country:US
Mailing Address - Phone:843-476-0736
Mailing Address - Fax:
Practice Address - Street 1:567 N OKATIE HWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-5078
Practice Address - Country:US
Practice Address - Phone:843-476-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3934225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant