Provider Demographics
NPI:1962707398
Name:CRYSTAL TWYNHAM MD PLC
Entity type:Organization
Organization Name:CRYSTAL TWYNHAM MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:ULANI
Authorized Official - Last Name:TWYNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-237-2265
Mailing Address - Street 1:15552 68TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3291
Mailing Address - Country:US
Mailing Address - Phone:931-237-2265
Mailing Address - Fax:612-594-8998
Practice Address - Street 1:15552 68TH PL N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3291
Practice Address - Country:US
Practice Address - Phone:931-237-2265
Practice Address - Fax:612-594-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-15
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39691261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN514517100Medicaid
MNF69382Medicare UPIN