1598767162 NPI number — CRYSTAL CARE HOME HEALTH SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598767162 NPI number — CRYSTAL CARE HOME HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CARE HOME HEALTH SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRYSTAL CARE HOME HEALTH SERVICES, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598767162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1675 REPUBLIC PARKWAY
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-203-2121
Provider Business Mailing Address Fax Number:
972-203-8384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 REPUBLIC PARKWAY
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-203-2121
Provider Business Practice Location Address Fax Number:
972-203-8384
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OMENUKOR
Authorized Official First Name:
KEYNA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
972-203-2121

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  006494 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000038800 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0008674000 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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