Healthcare Provider Details

I. General information

NPI: 1124557210
Provider Name (Legal Business Name): CRYSTAL RUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 POWER INN RD SUITE C
SACRAMENTO CA
95628
US

IV. Provider business mailing address

3600 POWER INN RD STE C
SACRAMENTO CA
95826-3826
US

V. Phone/Fax

Practice location:
  • Phone: 916-453-2704
  • Fax: 916-453-2708
Mailing address:
  • Phone: 916-453-2704
  • Fax: 916-453-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC28271214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: