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General NPI Number Information
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NPI Number | 1477176824
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Entity Type | Organization
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Legal Business Name | CRYSTALCARE
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Dates
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Enumeration Date | 05/20/2020
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Last Update Date | 11/18/2020
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Provider Practice Location Address
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Address Line | 3124 N SHILOH ROAD
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City | CORINTH
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State | MS
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Zip | 38834
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Country | US
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Telephone | 901-292-2964
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Fax | 662-762-0690
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Provider Business Mailing Address
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Address Line | PO BOX 488
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City | CORINTH
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State | MS
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Zip | 38835-0488
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Country | US
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Telephone | 662-486-2710
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Fax | 662-762-0690
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Authorized Official
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Title or Position | OWNER
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Name | CRYSTAL ROSE WILSON
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Credential | NP
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Telephone | 901-292-2964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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