1568702785 NPI number — NACHELLE CROUCH

Table of content: NACHELLE CROUCH (NPI 1568702785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568702785 NPI number — NACHELLE CROUCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROUCH
Provider First Name:
NACHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1568702785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8649 ORCUTT AVE APT F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23605-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-659-2142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 N FEDERAL HWY SUITE 2 SOUTH
Provider Second Line Business Practice Location Address:
BUTTERFLY EFFECTS LLC
Provider Business Practice Location Address City Name:
POMPANO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-880-9270
Provider Business Practice Location Address Fax Number:
954-342-0273
Provider Enumeration Date:
02/25/2013

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 701088137025 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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