Healthcare Provider Details

I. General information

NPI: 1720123318
Provider Name (Legal Business Name): CRYSTAL CARE CENTER OF MANSFIELD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 WYANDOTTE AVE.
MANSFIELD OH
44906-1940
US

IV. Provider business mailing address

1159 WYANDOTTE AVE
MANSFIELD OH
44906-1940
US

V. Phone/Fax

Practice location:
  • Phone: 419-747-2666
  • 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: JERRY SMITH
Title or Position: OWNER
Credential:
Phone: 419-747-2666