Healthcare Provider Details

I. General information

NPI: 1225928476
Provider Name (Legal Business Name): MISS CRYSTAL MARIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BLDG 25
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S # 304-D
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 949-815-0853
  • Fax: 714-456-2842
Mailing address:
  • Phone: 949-815-0853
  • Fax: 714-456-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: