Provider Demographics
NPI:1265821565
Name:CRYSTAL FERGUSON
Entity Type:Organization
Organization Name:CRYSTAL FERGUSON
Other - Org Name:CRYSTAL FERGUSON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INDEPENDENT PROVIDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LEVETTE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-693-5952
Mailing Address - Street 1:3452 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1333
Mailing Address - Country:US
Mailing Address - Phone:513-693-5952
Mailing Address - Fax:
Practice Address - Street 1:3452 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-1333
Practice Address - Country:US
Practice Address - Phone:513-693-5952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0055350Medicaid