Provider Demographics
NPI:1609012301
Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Entity Type:Organization
Organization Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Other - Org Name:CRYSTAL CLINIC ORTHOPAEDIC CENTER - KENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-670-4152
Mailing Address - Street 1:PO BOX 72434
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:330-668-7428
Mailing Address - Fax:330-666-2709
Practice Address - Street 1:2007 STATE ROUTE 59
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-7610
Practice Address - Country:US
Practice Address - Phone:330-673-6299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NOT APPLICABLE284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6166490002Medicare NSC