1619035912 NPI number — MR. KENNETH FREDRICK CRINKLAW MSPT, OCS

Table of content: MR. KENNETH FREDRICK CRINKLAW MSPT, OCS (NPI 1619035912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619035912 NPI number — MR. KENNETH FREDRICK CRINKLAW MSPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRINKLAW
Provider First Name:
KENNETH
Provider Middle Name:
FREDRICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT, OCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRINKLAW
Provider Other First Name:
KEN
Provider Other Middle Name:
FREDRICK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619035912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16261 REDMOND WAY
Provider Second Line Business Mailing Address:
# 100
Provider Business Mailing Address City Name:
REDMOND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98052-3833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-881-3001
Provider Business Mailing Address Fax Number:
425-881-3585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16261 REDMOND WAY
Provider Second Line Business Practice Location Address:
# 100
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-3833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-881-3001
Provider Business Practice Location Address Fax Number:
425-881-3585
Provider Enumeration Date:
12/05/2006

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: 225100000X , with the licence number:  PT00005937 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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