Provider Demographics
NPI:1477176824
Name:CRYSTALCARE
Entity Type:Organization
Organization Name:CRYSTALCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:901-292-2964
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0488
Mailing Address - Country:US
Mailing Address - Phone:662-486-2710
Mailing Address - Fax:662-762-0690
Practice Address - Street 1:3124 N SHILOH ROAD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:901-292-2964
Practice Address - Fax:662-762-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care