1275693921 NPI number — MR. LARRY GENE CRISP CFNP

Table of content: MR. LARRY GENE CRISP CFNP (NPI 1275693921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275693921 NPI number — MR. LARRY GENE CRISP CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISP
Provider First Name:
LARRY
Provider Middle Name:
GENE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CFNP
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:
1275693921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 COUNTY ROAD 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37322-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16850 STATE HIGHWAY 58 S STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37322-5259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-334-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2006

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: 363LF0000X , with the licence number:  APN 7946 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4053899 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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