Provider Demographics
NPI:1720477763
Name:CHARLES F CRANDALL DC PA
Entity type:Organization
Organization Name:CHARLES F CRANDALL DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-447-6779
Mailing Address - Street 1:1501 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3647
Mailing Address - Country:US
Mailing Address - Phone:727-447-6779
Mailing Address - Fax:727-462-2634
Practice Address - Street 1:1501 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3647
Practice Address - Country:US
Practice Address - Phone:727-447-6779
Practice Address - Fax:727-462-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1148135OtherAMERICAN SPECIALTY HEALTH
FL010609000Medicaid
55998OtherBLUE CROSS BLUE SHIELD
FL55998Medicare PIN