Provider Demographics
NPI:1023397528
Name:LAIL, CRAIG (LMT)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:LAIL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 POINSETTA AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4123
Mailing Address - Country:US
Mailing Address - Phone:386-325-8305
Mailing Address - Fax:386-325-8304
Practice Address - Street 1:3800 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3902
Practice Address - Country:US
Practice Address - Phone:386-325-8305
Practice Address - Fax:386-325-8304
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 333888172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker