Healthcare Provider Details

I. General information

NPI: 1629615000
Provider Name (Legal Business Name): TYRONE L CREW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 02/04/2024
Certification Date: 02/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 10TH AVE S APT 305
FARGO ND
58103-7088
US

IV. Provider business mailing address

4330 10TH AVE S APT 305
FARGO ND
58103-7088
US

V. Phone/Fax

Practice location:
  • Phone: 701-730-9365
  • Fax:
Mailing address:
  • Phone: 701-730-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TYRONE CREW
Title or Position: OWNER
Credential:
Phone: 701-730-9365