=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376557645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRNC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 05/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3423 PASCAGOULA ST
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39567-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-762-2345
-----------------------------------------------------
Fax | 228-762-2365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3423 PASCAGOULA ST
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39567-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-762-2345
-----------------------------------------------------
Fax | 228-762-2365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ADA RUTH BOSARGE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 228-762-2345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT2455
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT3565
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT0449
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------