Provider Demographics
NPI:1619409075
Name:CRYSTAL STONE LTD
Entity Type:Organization
Organization Name:CRYSTAL STONE LTD
Other - Org Name:NEW LEAF PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:618-416-7738
Mailing Address - Street 1:423 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1214
Mailing Address - Country:US
Mailing Address - Phone:618-416-7738
Mailing Address - Fax:877-295-7244
Practice Address - Street 1:423 N HIGH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1214
Practice Address - Country:US
Practice Address - Phone:618-806-7939
Practice Address - Fax:877-295-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1518328624Medicare PIN