Healthcare Provider Details

I. General information

NPI: 1366628554
Provider Name (Legal Business Name): CRYSTAL NEW HOPE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 DOUGLAS DR N
CRYSTAL MN
55422-2415
US

IV. Provider business mailing address

3501 DOUGLAS DR N
CRYSTAL MN
55422-2415
US

V. Phone/Fax

Practice location:
  • Phone: 763-535-9601
  • Fax: 763-535-5601
Mailing address:
  • Phone: 763-535-9601
  • Fax: 763-535-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROXANNE M URBASHICH
Title or Position: OFFICE MANAGER
Credential:
Phone: 763-535-9601