Basic Information
| Provider Information | |||||||||
| NPI: | 1891027843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROOKSVILLE FAMILY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 CHINA ST | ||||||||
| Address2: | P.O. BOX 159 | ||||||||
| City: | CROOKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437311124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409826872 | ||||||||
| FaxNumber: | 7409825551 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 CHINA ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437311124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409826872 | ||||||||
| FaxNumber: | 7409825551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2010 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | ANDERS | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7409826872 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CMM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.