Provider Demographics
NPI:1629615000
Name:TYRONE L CREW
Entity Type:Organization
Organization Name:TYRONE L CREW
Other - Org Name:MEDIATION OF THE SELF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:CREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-730-9365
Mailing Address - Street 1:4330 10TH AVE S APT 305
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7088
Mailing Address - Country:US
Mailing Address - Phone:701-730-9365
Mailing Address - Fax:
Practice Address - Street 1:4330 10TH AVE S APT 305
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7088
Practice Address - Country:US
Practice Address - Phone:701-730-9365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty