Provider Demographics
NPI:1558794263
Name:CRULL, ROBERT LINCOLN (ATC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LINCOLN
Last Name:CRULL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 PLEASANT CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-9757
Mailing Address - Country:US
Mailing Address - Phone:803-250-9645
Mailing Address - Fax:803-533-3801
Practice Address - Street 1:300 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4427
Practice Address - Country:US
Practice Address - Phone:803-250-9645
Practice Address - Fax:803-533-3801
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer