1083685291 NPI number — CRYSTAL D FAUDERE D.O.

Table of content: CRYSTAL D FAUDERE D.O. (NPI 1083685291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083685291 NPI number — CRYSTAL D FAUDERE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAUDERE
Provider First Name:
CRYSTAL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1083685291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67042-2184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-321-2010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67042-2184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-321-2010
Provider Business Practice Location Address Fax Number:
316-321-8871
Provider Enumeration Date:
01/27/2006

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: 207Q00000X , with the licence number:  530512 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200331140A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com