| Crystalcare | |
|
3124 N Shiloh Road Corinth MS 38834 | |
| (901) 292-2964 | |
| (662) 762-0690 |
| Full Name | Crystalcare |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 3124 N Shiloh Road, Corinth, Mississippi |
| Authorized Official Name and Position | Crystal Rose Wilson (OWNER) |
| Authorized Official Contact | 9012922964 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Crystalcare Po Box 488 Corinth MS 38835-0488 Ph: (662) 486-2710 | Crystalcare 3124 N Shiloh Road Corinth MS 38834 Ph: (901) 292-2964 |
| NPI Number | 1477176824 |
|---|---|
| Provider Enumeration Date | 05/20/2020 |
| Last Update Date | 11/18/2020 |
| Medicare PECOS PAC ID | 3779905252 |
|---|---|
| Medicare Enrollment ID | O20200630001138 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1477176824 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Secondary |
| 363LF0000X | Nurse Practitioner - Family | (* (Not Available)) | Primary |
| Provider Name | Crystal R Wilson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760786479 PECOS PAC ID: 1052595824 Enrollment ID: I20120314000506 |
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