Provider Demographics
NPI:1003032947
Name:CRYSTAL HEALTH CARE SERVICES, INC
Entity Type:Organization
Organization Name:CRYSTAL HEALTH CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-334-2311
Mailing Address - Street 1:1300 BAXTER STREET
Mailing Address - Street 2:SUITE 190
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3804
Mailing Address - Country:US
Mailing Address - Phone:704-334-2311
Mailing Address - Fax:704-334-2310
Practice Address - Street 1:1300 BAXTER STREET
Practice Address - Street 2:SUITE 190
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3804
Practice Address - Country:US
Practice Address - Phone:704-334-2311
Practice Address - Fax:704-334-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3464251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3412841Medicaid