Healthcare Provider Details

I. General information

NPI: 1063009702
Provider Name (Legal Business Name): CRYSTAL A MCLENDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 CASTLEBAR ST NW
CANTON OH
44708-2045
US

IV. Provider business mailing address

4805 CASTLEBAR ST NW
CANTON OH
44708-2045
US

V. Phone/Fax

Practice location:
  • Phone: 330-430-9662
  • Fax:
Mailing address:
  • Phone: 330-430-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number2573442
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number2573442
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number2573442
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number2573442
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number2573442
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number2573442
License Number StateOH
# 10
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number2573442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: