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General NPI Number Information
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NPI Number | 1932479045
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Entity Type | Organization
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Legal Business Name | CRYSTAL E.NICKERSON, LLC
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 01/05/2012
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Provider Practice Location Address
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Address Line | 2302 W MEADOWVIEW RD SUITE 228, BOX 24
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City | GREENSBORO
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State | NC
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Zip | 27407-3721
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Country | US
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Telephone | 336-617-0764
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Fax | 336-617-0964
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Provider Business Mailing Address
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Address Line | 2302 W MEADOWVIEW RD SUITE 228, BOX 24
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City | GREENSBORO
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State | NC
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Zip | 27407-3721
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Country | US
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Telephone | 336-617-0764
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Fax | 336-617-0964
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. CRYSTAL EYVETTE NICKERSON
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Credential | BA
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Telephone | 336-617-0764
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number |
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License Number State |
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