Healthcare Provider Details

I. General information

NPI: 1649391855
Provider Name (Legal Business Name): CHARLES J CROAL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHUCK CROAL

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51600 HUNTINGTON RD SUITE B
LAPINE OR
97739-9626
US

IV. Provider business mailing address

805 SW INDUSTRIAL WAY SUITE 3
BEND OR
97702-1093
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-7443
  • Fax: 541-536-7805
Mailing address:
  • Phone: 541-585-2529
  • Fax: 541-585-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2583
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier158751
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: