Provider Demographics
NPI:1962691147
Name:CRYSTAL HOME CARE LLC
Entity type:Organization
Organization Name:CRYSTAL HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:B
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:816-474-1814
Mailing Address - Street 1:4001 BLUE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64130-2350
Mailing Address - Country:US
Mailing Address - Phone:816-474-1814
Mailing Address - Fax:816-474-1861
Practice Address - Street 1:4001 BLUE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64130-2350
Practice Address - Country:US
Practice Address - Phone:816-474-1814
Practice Address - Fax:816-474-1861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19677111251E00000X
372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19677111OtherMISSOURI EMPLOYER IDENTIF