Healthcare Provider Details

I. General information

NPI: 1366002321
Provider Name (Legal Business Name): CRYSTAL CLINIC ORTHOPAEDIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 FULTON DR NW
CANTON OH
44718-2864
US

IV. Provider business mailing address

PO BOX 72434
CLEVELAND OH
44192-0002
US

V. Phone/Fax

Practice location:
  • Phone: 330-668-4065
  • Fax: 330-668-4082
Mailing address:
  • Phone: 330-668-4040
  • Fax: 330-664-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL J FERRY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 330-670-4152