Healthcare Provider Details

I. General information

NPI: 1235806183
Provider Name (Legal Business Name): MS. CRYSTAL MARIE BASLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-7732
  • Fax:
Mailing address:
  • Phone: 603-650-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1120
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: