1093825960 NPI number — REBECCA CRISTINE MCCRACKEN DPT

Table of content: REBECCA CRISTINE MCCRACKEN DPT (NPI 1093825960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093825960 NPI number — REBECCA CRISTINE MCCRACKEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCRACKEN
Provider First Name:
REBECCA
Provider Middle Name:
CRISTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1093825960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 YORKTOWNE BLVD
Provider Second Line Business Mailing Address:
APT 5802
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32129-6008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-562-7233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N SWALLOWTAIL DR
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32129-6102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-322-4641
Provider Business Practice Location Address Fax Number:
386-322-4677
Provider Enumeration Date:
08/30/2006

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:  PT21556 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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