Healthcare Provider Details

I. General information

NPI: 1982148672
Provider Name (Legal Business Name): CRYSTAL ROSE TANK DAOM, LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3239 ADAMS AVE
SAN DIEGO CA
92116-1645
US

IV. Provider business mailing address

3239 ADAMS AVE
SAN DIEGO CA
92116-1645
US

V. Phone/Fax

Practice location:
  • Phone: 619-546-4806
  • Fax:
Mailing address:
  • Phone: 619-546-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60723656
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA60448826
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number3134
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC20186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: