Provider Demographics
NPI:1164468823
Name:CRATER CHILD DEVELOPMENT CLINIC
Entity Type:Organization
Organization Name:CRATER CHILD DEVELOPMENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-863-1663
Mailing Address - Street 1:2002 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2112
Mailing Address - Country:US
Mailing Address - Phone:804-862-6186
Mailing Address - Fax:804-862-6276
Practice Address - Street 1:2002 WAKEFIELD STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2112
Practice Address - Country:US
Practice Address - Phone:804-862-6186
Practice Address - Fax:804-862-6276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare