Healthcare Provider Details

I. General information

NPI: 1649962275
Provider Name (Legal Business Name): CRAIG A MEILUTIS LPN CASE MANAGEMENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8242
  • Fax: 270-956-0223
Mailing address:
  • Phone: 270-798-8242
  • Fax: 270-956-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number217984
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number217984
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: