Healthcare Provider Details

I. General information

NPI: 1376002352
Provider Name (Legal Business Name): CHRYSTA IROLLA MS, MSPO, CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 4TH ST RM M5302
SAN FRANCISCO CA
94143-2350
US

IV. Provider business mailing address

400 PARNASSUS AVE # 614
SAN FRANCISCO CA
94143-2202
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1788
  • Fax:
Mailing address:
  • Phone: 415-476-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: