Provider Demographics
NPI:1508378480
Name:GROTH, CRYSTAL LYNN ROSE (DC)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LYNN ROSE
Last Name:GROTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 PARKLAWN AVE APT 224
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4675
Mailing Address - Country:US
Mailing Address - Phone:952-594-2203
Mailing Address - Fax:
Practice Address - Street 1:122 TYLER RD S
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-1733
Practice Address - Country:US
Practice Address - Phone:651-388-8113
Practice Address - Fax:651-388-8113
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor