Provider Demographics
NPI:1609919547
Name:KATHLEEN L CRAVEN
Entity Type:Organization
Organization Name:KATHLEEN L CRAVEN
Other - Org Name:RANDOLPH OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-625-4456
Mailing Address - Street 1:407 S COX ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203
Mailing Address - Country:US
Mailing Address - Phone:336-625-4456
Mailing Address - Fax:336-625-3933
Practice Address - Street 1:407 S COX ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5716
Practice Address - Country:US
Practice Address - Phone:336-625-4456
Practice Address - Fax:336-625-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-06-25
Deactivation Date:2007-03-21
Deactivation Code:
Reactivation Date:2008-03-06
Provider Licenses
StateLicense IDTaxonomies
NC756156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0176750001Medicare NSC