Healthcare Provider Details

I. General information

NPI: 1457751836
Provider Name (Legal Business Name): CRYSTAL MCFADDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3748 JULIET LEIA CIR S
JACKSONVILLE FL
32218-2955
US

IV. Provider business mailing address

3748 JULIET LEIA CIR S
JACKSONVILLE FL
32218-2955
US

V. Phone/Fax

Practice location:
  • Phone: 904-866-9216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906582
License Number StateFL

VIII. Authorized Official

Name: MS. CRYSTAL DENISE MCFADDEN
Title or Position: PROVIDER
Credential:
Phone: 904-866-9216