Provider Demographics
NPI:1972668770
Name:CRAIG M CARLSON
Entity Type:Organization
Organization Name:CRAIG M CARLSON
Other - Org Name:AVALON REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-596-9799
Mailing Address - Street 1:18821 DELAWARE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1935
Mailing Address - Country:US
Mailing Address - Phone:714-596-9799
Mailing Address - Fax:714-596-9739
Practice Address - Street 1:18821 DELAWARE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1935
Practice Address - Country:US
Practice Address - Phone:714-596-9799
Practice Address - Fax:714-596-9739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W16204Medicare PIN