=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760334791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL SUITS SA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2026
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 FRIENDSHIP RD STE 110
-----------------------------------------------------
City | BRASELTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30517-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-210-2180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8210 NOBLE VINES DR
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-6145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-244-5050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 17-566
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------