Basic Information
| Provider Information | |||||||||
| NPI: | 1336399724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROUSS | ||||||||
| FirstName: | CARY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1813 POINT VIEW DR | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956675008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304094370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 838 BEACH CT. | ||||||||
| Address2: | |||||||||
| City: | COLOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | 5306267934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9009 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9009 | 01 | CA | CAARR | OTHER |