MEDICARE: MR. CLARENCE EDWARD CROWE II CPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PRO60, ORF 16	FL

General Provider Information

NPI Number	:	1356577134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARENCE EDWARD CROWE II CPO

Provider Business Mailing Address
First Line	:	5640 N GALLOWAY RD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-2704
Country	:	US
Telephone Number	:	863-581-5833
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3001
Country	:	US
Telephone Number	:	863-853-1833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2009
Last Update Date	:	06/23/2009

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