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General NPI Number Information
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NPI Number | 1235726183
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Entity Type | Organization
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Legal Business Name | CRYSTAL SPRINGS HOME, INC.
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Dates
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Enumeration Date | 12/27/2020
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Last Update Date | 12/30/2020
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Provider Practice Location Address
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Address Line | 799 MOUNT ETNA RD
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City | PIKETON
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State | OH
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Zip | 45661-1101
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Country | US
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Telephone | 740-493-2380
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 845
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City | PIKETON
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State | OH
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Zip | 45661-0845
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Country | US
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Telephone | 740-493-2380
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | FREDERICKA WAGNER
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Credential |
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Telephone | 740-493-2380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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