Provider Demographics
NPI:1598452468
Name:CROWN CRANIAL & ORTHOTICS, LLC
Entity Type:Organization
Organization Name:CROWN CRANIAL & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-599-7140
Mailing Address - Street 1:1148 JEANNE CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-0027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1148 JEANNE CT
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-0027
Practice Address - Country:US
Practice Address - Phone:563-599-7140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier