Healthcare Provider Details

I. General information

NPI: 1205307774
Provider Name (Legal Business Name): EDITHA MANUEL CRISOSTOMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 GREY OWL CIR
ROSEVILLE CA
95661-4005
US

IV. Provider business mailing address

1473 GREY OWL CIR
ROSEVILLE CA
95661-4005
US

V. Phone/Fax

Practice location:
  • Phone: 916-517-8099
  • Fax:
Mailing address:
  • Phone: 916-517-8099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number21583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: