1992780704 NPI number — MR. ARIC N CRAVEN DPT

Table of content: MR. ARIC N CRAVEN DPT (NPI 1992780704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992780704 NPI number — MR. ARIC N CRAVEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAVEN
Provider First Name:
ARIC
Provider Middle Name:
N
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1992780704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 435
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNER
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57580-0435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-842-7188
Provider Business Mailing Address Fax Number:
605-842-7189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 E 8TH ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
WINNER
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57580-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-842-7188
Provider Business Practice Location Address Fax Number:
605-842-7189
Provider Enumeration Date:
12/14/2005

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:  1139 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025389600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22475 . This is a "SANDFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5833320 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0008438 . This is a "WELLMARK" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9192237 . This is a "DAKOTA CARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5833322 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10171 . This is a "AVERA HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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