Healthcare Provider Details

I. General information

NPI: 1366829319
Provider Name (Legal Business Name): CRYSTAL CLEAR HOME HEALTH AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6739 HARE HILL DR
ARLINGTON TN
38002-4846
US

IV. Provider business mailing address

6739 HARE HILL DRIVR
ARLINGTON TN
38002
US

V. Phone/Fax

Practice location:
  • Phone: 901-428-5525
  • Fax:
Mailing address:
  • Phone: 901-428-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: VERONICA LYNN WILSON
Title or Position: CEO
Credential:
Phone: 901-428-5525