1255780441 NPI number — CRISP & ASSOCIATES II, LLC

Table of content: (NPI 1255780441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255780441 NPI number — CRISP & ASSOCIATES II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRISP & ASSOCIATES II, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHRISTIANS HEALTH SERVICES
Provider Other Organization Name Type Code:
3
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:
1255780441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4980 PHILLIPS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30297-1472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-362-2990
Provider Business Mailing Address Fax Number:
404-362-2994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4980 PHILLIPS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297-1472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-362-2990
Provider Business Practice Location Address Fax Number:
404-362-2994
Provider Enumeration Date:
06/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CRISP
Authorized Official First Name:
RAY
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-362-2990

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHHH000063 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHHH000063 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336H0001X , with the licence number: PHHH000063 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PHHH000063 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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