Healthcare Provider Details

I. General information

NPI: 1669590790
Provider Name (Legal Business Name): CRYSTAL COMMUNITY E N T
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 SE 5TH TER
CRYSTAL RIVER FL
34429-4852
US

IV. Provider business mailing address

790 SE 5TH TER
CRYSTAL RIVER FL
34429-4852
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-0011
  • Fax: 352-795-9481
Mailing address:
  • Phone: 352-795-0011
  • Fax: 352-795-9481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberOS5716
License Number StateFL

VIII. Authorized Official

Name: MRS. KELLY SURRENCY
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-795-0011