Provider Demographics
NPI:1457966327
Name:CRYSTAL CLINIC, INC.
Entity Type:Organization
Organization Name:CRYSTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COZZONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-668-6785
Mailing Address - Street 1:3925 EMBASSY PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1799
Mailing Address - Country:US
Mailing Address - Phone:330-668-4040
Mailing Address - Fax:
Practice Address - Street 1:2383 S MAIN ST STE D106
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-1190
Practice Address - Country:US
Practice Address - Phone:330-670-4046
Practice Address - Fax:330-670-4047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty