Provider Demographics
NPI:1114634227
Name:CRYSTAL CLEAR TRANSPORTATION LLC
Entity Type:Organization
Organization Name:CRYSTAL CLEAR TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:FATMATA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-571-8769
Mailing Address - Street 1:7924 HEADWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8070
Mailing Address - Country:US
Mailing Address - Phone:614-571-8769
Mailing Address - Fax:
Practice Address - Street 1:7924 HEADWATER DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8070
Practice Address - Country:US
Practice Address - Phone:614-571-8769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)