Basic Information
| Provider Information | |||||||||
| NPI: | 1700483567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRANIO NINJA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W STE 301 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 975 N MAIN ST STE 3A | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840412200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017029191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRINER | ||||||||
| AuthorizedOfficialFirstName: | DEVAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8017029191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.