Organization · NPI-2

Crystal Bastin MD LLC

Family Medicine · South Charleston, WV

NPI number1053539387
StatusActive
Last updated in NPPESNov 12, 2013

Details

NPI
1053539387
Entity type
Organization (NPI-2)
Legal business name
Crystal Bastin MD LLC
Organization subpart
No
Enumeration date
Apr 23, 2007
Last updated
Nov 12, 2013

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
207Q00000X Family Medicine20368WVYes

Practice location

4820 Kentucky St
South Charleston, WV 25309-1310

Phone 304-720-0390

Mailing address

4820 Kentucky Street
South Charleston, WV 25309-1364

Phone 304-720-0390

Authorized official

Shannon G Davis
Office Manager
3047200390

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