Provider Demographics
NPI:1255807186
Name:COMANCHE, CRAIG (CIT)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:COMANCHE
Suffix:
Gender:M
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PARKWEST DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5329
Mailing Address - Country:US
Mailing Address - Phone:318-789-9910
Mailing Address - Fax:318-509-8452
Practice Address - Street 1:216 OUACHITA AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-8513
Practice Address - Country:US
Practice Address - Phone:318-322-4770
Practice Address - Fax:318-509-8452
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4199171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4199OtherSTATE OF LOUISIANA THE ADDICTIVE DISORDER REGULATORY AUTHORITY