Healthcare Provider Details

I. General information

NPI: 1295772770
Provider Name (Legal Business Name): CRYSTAL MIYAKE MSCCCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3099 RIVER RD S STE 150
SALEM OR
97302-9754
US

IV. Provider business mailing address

3099 RIVER RD S STE 150
SALEM OR
97302-9754
US

V. Phone/Fax

Practice location:
  • Phone: 503-485-2581
  • Fax: 503-485-2564
Mailing address:
  • Phone: 503-485-2581
  • Fax: 503-485-2564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberLD00004248
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number022558
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: