Provider Demographics
NPI:1053434761
Name:CRAWFORD CO R-II
Entity type:Organization
Organization Name:CRAWFORD CO R-II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORSUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-2534
Mailing Address - Street 1:1 WILDCAT PRIDE DR
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-1549
Mailing Address - Country:US
Mailing Address - Phone:573-885-2534
Mailing Address - Fax:573-885-3900
Practice Address - Street 1:1 WILDCAT PRIDE DR
Practice Address - Street 2:CRAWFORD CO R-II
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1549
Practice Address - Country:US
Practice Address - Phone:573-885-2534
Practice Address - Fax:573-885-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506075100Medicaid