Healthcare Provider Details

I. General information

NPI: 1912191974
Provider Name (Legal Business Name): CRYSTAL D CRESTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 TREMONT ST
HOPEDALE IL
61747-0267
US

IV. Provider business mailing address

107 TREMONT
HOPEDALE IL
61747-0267
US

V. Phone/Fax

Practice location:
  • Phone: 309-449-4332
  • Fax: 309-449-4016
Mailing address:
  • Phone: 309-449-4332
  • Fax: 309-449-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: