Provider Demographics
NPI:1770245433
Name:CAPTIVATING CROWN LLC
Entity Type:Organization
Organization Name:CAPTIVATING CROWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-506-4247
Mailing Address - Street 1:1325 ROCK QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5088
Mailing Address - Country:US
Mailing Address - Phone:770-506-4247
Mailing Address - Fax:
Practice Address - Street 1:1325 ROCK QUARRY RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5088
Practice Address - Country:US
Practice Address - Phone:770-506-4247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309-628398Medicaid