Healthcare Provider Details

I. General information

NPI: 1346890894
Provider Name (Legal Business Name): CRYSTAL JUNE GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

IV. Provider business mailing address

10924 UPLAND TERRACE DR
LEBANON IL
62254-2335
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-7018
  • Fax:
Mailing address:
  • Phone: 760-264-5165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: