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NPI Code Detail

MEDICARE: CRYSTAL ROSE STREET AU.D.

MEDICARE: CRYSTAL ROSE STREET AU.D.
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
1231H00000XAudiologist23002486AIN

General Provider Information

NPI Number : 1972801504
Entity Type Code : Individual
Provider Name (Legal Business Name) : CRYSTAL ROSE STREET AU.D.
Provider Business Mailing Address
First Line : 1200 E 42ND ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46205-2004
Country : US
Telephone Number : 317-941-4637
Fax Number : 317-920-6350
Provider Business Practice Location Address
First Line : 1200 E 42ND ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46205-2004
Country : US
Telephone Number : 317-941-4637
Fax Number : 317-920-6350
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/07/2011
Last Update Date : 03/07/2011

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Directions to “ CRYSTAL ROSE STREET AU.D.” Practice Location

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