Healthcare Provider Details

I. General information

NPI: 1801254883
Provider Name (Legal Business Name): CRYSTAL CARE OF IRONTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 1/2 MARION PIKE
COAL GROVE OH
45638-3070
US

IV. Provider business mailing address

2968 JERICHO PL
DELAWARE OH
43015-3175
US

V. Phone/Fax

Practice location:
  • Phone: 740-532-0449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateOH

VIII. Authorized Official

Name: PAUL B BERGSTEN
Title or Position: CEO
Credential:
Phone: 937-825-6622