1033731971 NPI number — CRYSTAL WRAPE CASE MANAGER II

Table of content: CRYSTAL WRAPE CASE MANAGER II (NPI 1033731971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033731971 NPI number — CRYSTAL WRAPE CASE MANAGER II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRAPE
Provider First Name:
CRYSTAL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CASE MANAGER II
Provider Gender Code:
F

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:
1033731971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1976 COUNTY ROAD 4236
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONHAM
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75418-9535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-815-3958
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 W UNIVERSITY BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74701-2970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-924-7331
Provider Business Practice Location Address Fax Number:
580-924-7332
Provider Enumeration Date:
05/14/2020

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100728830A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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