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General NPI Number Information
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NPI Number | 1114201423
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Entity Type | Organization
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Legal Business Name | ROBERT CROCKETT ENTERPRISE LLC
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Dates
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Enumeration Date | 10/05/2011
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Last Update Date | 10/05/2011
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Provider Practice Location Address
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Address Line | 2310 4TH ST SUITE A
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City | MERIDIAN
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State | MS
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Zip | 39301-5819
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Country | US
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Telephone | 601-286-3745
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Fax |
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Provider Business Mailing Address
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Address Line | 2310 4TH ST SUITE A
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City | MERIDIAN
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State | MS
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Zip | 39301-5819
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ROBERT S CROCKETT
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Credential | DPM
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Telephone | 601-286-3745
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 80193
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License Number State | MS
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