Healthcare Provider Details

I. General information

NPI: 1760055388
Provider Name (Legal Business Name): CRYSTALS KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BELLFLOWER AVE NW
CANTON OH
44708-5606
US

IV. Provider business mailing address

242 BELLFLOWER AVE NW
CANTON OH
44708-5606
US

V. Phone/Fax

Practice location:
  • Phone: 330-284-5702
  • Fax:
Mailing address:
  • Phone: 330-284-5702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CRYSTAL C SMITH
Title or Position: OWNER
Credential:
Phone: 330-284-5702