1063668127 NPI number — SANDIE LOUISE MCCRACKEN CADC II, AAS

Table of content: SANDIE LOUISE MCCRACKEN CADC II, AAS (NPI 1063668127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063668127 NPI number — SANDIE LOUISE MCCRACKEN CADC II, AAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCRACKEN
Provider First Name:
SANDIE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC II, AAS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NELSON
Provider Other First Name:
SANDIE
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063668127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1121
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470-0254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-672-2691
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 5TH ST # 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-408-8941
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2008

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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