Provider Demographics
NPI:1962553602
Name:RIDER, CRYSTAL ANN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:RIDER
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 1:517 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1107
Mailing Address - Country:US
Mailing Address - Phone:419-732-0960
Mailing Address - Fax:
Practice Address - Street 1:517 E 3RD ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1107
Practice Address - Country:US
Practice Address - Phone:419-732-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide