Provider Demographics
NPI:1386398634
Name:SELBURG, CRYSTAL MARIE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:SELBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-1248
Mailing Address - Country:US
Mailing Address - Phone:701-953-7036
Mailing Address - Fax:
Practice Address - Street 1:3936 BIA ROAD 12
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-3834
Practice Address - Country:US
Practice Address - Phone:701-244-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant