MEDICARE: CRYSTAL SPRING MCLAUGHLIN LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00021651	WA

General Provider Information

NPI Number	:	1255592937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL SPRING MCLAUGHLIN LMP

Provider Business Mailing Address
First Line	:	920 VALLEY MALL PKWY
Second Line	:
City	:	EAST WENATCHEE
State	:	WA
Zip	:	98802-4402
Country	:	US
Telephone Number	:	509-886-0559
Fax Number	:	509-886-0559

Provider Business Practice Location Address
First Line	:	920 VALLEY MALL PKWY
Second Line	:
City	:	EAST WENATCHEE
State	:	WA
Zip	:	98802-4402
Country	:	US
Telephone Number	:	509-886-0559
Fax Number	:	509-886-0559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/24/2008

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