Healthcare Provider Details

I. General information

NPI: 1730915794
Provider Name (Legal Business Name): KEYAIRA CRUDUP CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10320 FELD FARM LN STE 200
CHARLOTTE NC
28210-8484
US

IV. Provider business mailing address

10320 FELD FARM LN STE 200
CHARLOTTE NC
28210-8484
US

V. Phone/Fax

Practice location:
  • Phone: 704-707-0014
  • Fax:
Mailing address:
  • Phone: 704-707-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO05262
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO05262
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: