Provider Demographics
NPI:1821586223
Name:AMY KRYSTOCK LLC
Entity Type:Organization
Organization Name:AMY KRYSTOCK LLC
Other - Org Name:THE PLANO PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:203-318-6037
Mailing Address - Street 1:560 RIVER RD APT 33
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4593
Mailing Address - Country:US
Mailing Address - Phone:203-671-3392
Mailing Address - Fax:
Practice Address - Street 1:500 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3530
Practice Address - Country:US
Practice Address - Phone:203-671-3392
Practice Address - Fax:888-855-7803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300057442OtherMEDICARE NUMBER