Provider Demographics
NPI:1982148672
Name:TANK, CRYSTAL ROSE (DAOM, LMP)
Entity type:Individual
Prefix:
First Name:CRYSTAL ROSE
Middle Name:
Last Name:TANK
Suffix:
Gender:
Credentials:DAOM, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1645
Mailing Address - Country:US
Mailing Address - Phone:619-546-4806
Mailing Address - Fax:
Practice Address - Street 1:3239 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1645
Practice Address - Country:US
Practice Address - Phone:619-546-4806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60723656171100000X
WAMA60448826172M00000X
CA3134172M00000X
CAAC20186171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist