Provider Demographics
NPI:1942851902
Name:AUSTIN, CRYSTAL M (CEO/ONWER)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:M
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:CEO/ONWER
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:M
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CEO/OWNER
Mailing Address - Street 1:1640 RIBAUT RD APT 132
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-1747
Mailing Address - Country:US
Mailing Address - Phone:843-929-8597
Mailing Address - Fax:
Practice Address - Street 1:1640 RIBAUT RD APT 132
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1747
Practice Address - Country:US
Practice Address - Phone:843-929-8597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20144253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care