=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619190329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN DELANE CRUTCHFIELD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 05/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2215 N MIDLAND DR 4-A
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-889-4289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3506 HYDE PARK AVE
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-5713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-697-6377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1134419
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------