1659325538 NPI number — WALTER JOHN CRAWFORD PT

Table of content: WALTER JOHN CRAWFORD PT (NPI 1659325538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659325538 NPI number — WALTER JOHN CRAWFORD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
WALTER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1659325538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4120 69TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95820-3416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-739-0653
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6960 DESTINY DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95677-2993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-625-9295
Provider Business Practice Location Address Fax Number:
916-625-9298
Provider Enumeration Date:
05/22/2006

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:  PT32677 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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