1184200248 NPI number — KRISBIN MEDICAL LLC

Table of content: (NPI 1184200248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184200248 NPI number — KRISBIN MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISBIN MEDICAL LLC
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:
CORDIAL CARE FAMILY PRACTICE
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:
1184200248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 OAK DR S STE 501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE JACKSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77566-5789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-267-7722
Provider Business Mailing Address Fax Number:
979-428-1199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 OAK DR S STE 501
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE JACKSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77566-5789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-267-7722
Provider Business Practice Location Address Fax Number:
979-428-1199
Provider Enumeration Date:
03/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BINU
Authorized Official First Name:
AUGNES
Authorized Official Middle Name:
CHRISTY
Authorized Official Title or Position:
FNP-C, ACNPC-AG
Authorized Official Telephone Number:
979-267-7722

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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