MEDICARE: CRYSTAL TRAINING INSTITUTE, LLC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1811703457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL TRAINING INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	880 S VIEW DR STE 15132
Second Line	:
City	:	MOSINEE
State	:	WI
Zip	:	54455-8205
Country	:	US
Telephone Number	:	715-432-4921
Fax Number	:

Provider Business Practice Location Address
First Line	:	880 S VIEW DR STE 15132
Second Line	:
City	:	MOSINEE
State	:	WI
Zip	:	54455-8205
Country	:	US
Telephone Number	:	715-298-2104
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	SAMUEL ZIMMERMAN
Credential	:
Telephone Number	:	715-298-2104

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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