Provider Demographics
NPI:1649494675
Name:DEPRIEST, KRAIG LAMONT (RPT)
Entity type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:LAMONT
Last Name:DEPRIEST
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 W CHAPMAN LN
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2347
Mailing Address - Country:US
Mailing Address - Phone:310-419-9985
Mailing Address - Fax:
Practice Address - Street 1:3699 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2719
Practice Address - Country:US
Practice Address - Phone:323-783-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist