Healthcare Provider Details

I. General information

NPI: 1699382275
Provider Name (Legal Business Name): KRYSTAL BEST CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N PORTLAND AVE
BROOKLYN NY
11205-2005
US

IV. Provider business mailing address

100 N PORTLAND AVE
BROOKLYN NY
11205-2005
US

V. Phone/Fax

Practice location:
  • Phone: 718-260-4835
  • Fax: 718-260-4801
Mailing address:
  • Phone: 718-260-4835
  • Fax: 718-260-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number107929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: