Healthcare Provider Details

I. General information

NPI: 1922711696
Provider Name (Legal Business Name): CRYSTALLINITY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20905 GREENFIELD RD STE 207
SOUTHFIELD MI
48075-5346
US

IV. Provider business mailing address

20905 GREENFIELD RD STE 207
SOUTHFIELD MI
48075-5346
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-1911
  • Fax:
Mailing address:
  • Phone: 248-559-1911
  • Fax: 248-559-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CRYSTAL RENEE LEE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 248-559-1911