Healthcare Provider Details

I. General information

NPI: 1932794005
Provider Name (Legal Business Name): CRYSTAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 DAUPHINE DR
FALLS CHURCH VA
22042-3724
US

IV. Provider business mailing address

3311 DAUPHINE DR
FALLS CHURCH VA
22042-3724
US

V. Phone/Fax

Practice location:
  • Phone: 301-526-6199
  • Fax:
Mailing address:
  • Phone: 301-526-6199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State

VIII. Authorized Official

Name: ABABIO GYEBI
Title or Position: CEO
Credential:
Phone: 301-526-6199