Provider Demographics
NPI:1659157949
Name:KRAGH, MATTHEW LANE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LANE
Last Name:KRAGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 STATE ROUTE 181
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-9608
Mailing Address - Country:US
Mailing Address - Phone:419-612-2111
Mailing Address - Fax:
Practice Address - Street 1:691 STATE ROUTE 181
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-9608
Practice Address - Country:US
Practice Address - Phone:419-612-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications