Provider Demographics
NPI:1184295123
Name:CROCKETT FOUNDATION INC
Entity type:Organization
Organization Name:CROCKETT FOUNDATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:REGINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANZKI
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:954-822-9370
Mailing Address - Street 1:401 SW 1ST AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2853
Mailing Address - Country:US
Mailing Address - Phone:754-666-3928
Mailing Address - Fax:
Practice Address - Street 1:401 SW 1ST AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2853
Practice Address - Country:US
Practice Address - Phone:754-666-3928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health