Provider Demographics
NPI:1497817258
Name:KINGREA, CRAIG L (PT)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:L
Last Name:KINGREA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 DEVAL DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1902
Mailing Address - Country:US
Mailing Address - Phone:985-778-3177
Mailing Address - Fax:
Practice Address - Street 1:1311 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3015
Practice Address - Country:US
Practice Address - Phone:985-649-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A354CS21Medicare PIN
LA3A265BD21Medicare PIN
LA3A354CS21Medicare UPIN
LA3A265BD21Medicare UPIN