Provider Demographics
NPI:1043609779
Name:CRYSTAL CLEAR NUTRITION, PLLC
Entity Type:Organization
Organization Name:CRYSTAL CLEAR NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEIN
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:315-717-2202
Mailing Address - Street 1:420 E GERMAN ST STE 103A
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1042
Mailing Address - Country:US
Mailing Address - Phone:315-717-2202
Mailing Address - Fax:800-891-4959
Practice Address - Street 1:420 E GERMAN ST STE 103A
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1042
Practice Address - Country:US
Practice Address - Phone:315-717-2202
Practice Address - Fax:800-891-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0053821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ300050203OtherMEDICARE PTAN
NY04800005382Medicaid