Healthcare Provider Details

I. General information

NPI: 1154071017
Provider Name (Legal Business Name): CRYSTAL KAY GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5015 CANYON CREST DR STE 201
RIVERSIDE CA
92507-6020
US

IV. Provider business mailing address

5015 CANYON CREST DR STE 201
RIVERSIDE CA
92507-6020
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-9806
  • Fax:
Mailing address:
  • Phone: 951-363-9806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License NumberL9696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: