=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013677103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC CREWS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2021
-----------------------------------------------------
Last Update Date | 12/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 WESTSIDE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27405-7116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-230-1103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 OLD QUARRY RD
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-0409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-709-8431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 0002099265
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------