Healthcare Provider Details

I. General information

NPI: 1891799797
Provider Name (Legal Business Name): DONNA LOUISE CRIKOS RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BOATYARD DR STE A
FORT BRAGG CA
95437-5751
US

IV. Provider business mailing address

PO BOX 2740
FORT BRAGG CA
95437-2740
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-1208
  • Fax: 707-964-2269
Mailing address:
  • Phone: 707-964-6848
  • Fax: 707-964-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT11908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: