Provider Demographics
NPI:1417786906
Name:CRIDER, CALVIN ROSS
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:ROSS
Last Name:CRIDER
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 1:1109 BROADWAY ST APT 7
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-6149
Mailing Address - Country:US
Mailing Address - Phone:409-526-2179
Mailing Address - Fax:
Practice Address - Street 1:1109 BROADWAY ST APT 7
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-6149
Practice Address - Country:US
Practice Address - Phone:409-526-2179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27322910342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company