1093183824 NPI number — CRANIAL TECHNOLOGIES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093183824 NPI number — CRANIAL TECHNOLOGIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRANIAL TECHNOLOGIES INC
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:
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:
1093183824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 W AUTO DR FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85284-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-362-2263
Provider Business Mailing Address Fax Number:
480-705-0960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2902 N ORANGE AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32804-4605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-362-2263
Provider Business Practice Location Address Fax Number:
844-595-5183
Provider Enumeration Date:
09/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
NATIONAL FACILITY DIRECTOR
Authorized Official Telephone Number:
866-362-2263

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016330900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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