=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053504639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANE MEDICAL CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 S GASTON ST
-----------------------------------------------------
City | CRANE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79731-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-558-2223
-----------------------------------------------------
Fax | 432-558-2208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 S GASTON ST
-----------------------------------------------------
City | CRANE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79731-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-558-2223
-----------------------------------------------------
Fax | 432-558-2208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | JOSE GUMATO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 432-558-2223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------