1568602829 NPI number — TYRONE CROSS LPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568602829 NPI number — TYRONE CROSS LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSS
Provider First Name:
TYRONE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568602829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 GREEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASO ROBLES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93446-4415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-739-8706
Provider Business Mailing Address Fax Number:
805-739-8738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 CARMEN LN STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93458-7771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-739-8706
Provider Business Practice Location Address Fax Number:
805-739-8738
Provider Enumeration Date:
02/26/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  PT31258 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 94-1735271 . This is a "CARES CRISIS RESIDENTIAL NORTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1689762486 . This is a "TELECARE CARES CRISIS RESIDENTIAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".