Provider Demographics
NPI:1861002396
Name:CRAWFORD, LACEDRIC
Entity Type:Individual
Prefix:
First Name:LACEDRIC
Middle Name:
Last Name:CRAWFORD
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 1:13055 GARDEN CREEK LANE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473
Mailing Address - Country:US
Mailing Address - Phone:205-292-4538
Mailing Address - Fax:
Practice Address - Street 1:13055 GARDEN CREEK LANE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473
Practice Address - Country:US
Practice Address - Phone:205-292-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRES888018372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider