1184953754 NPI number — MRS. CRYSTAL BLEU STEVENSON OTR

Table of content: MRS. CRYSTAL BLEU STEVENSON OTR (NPI 1184953754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184953754 NPI number — MRS. CRYSTAL BLEU STEVENSON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENSON
Provider First Name:
CRYSTAL
Provider Middle Name:
BLEU
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BATTIN
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
BLEU
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184953754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6091 WINTERGREEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92647-6463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-496-2299
Provider Business Mailing Address Fax Number:
866-274-0162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6091 WINTERGREEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92647-6463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-496-2299
Provider Business Practice Location Address Fax Number:
866-274-0162
Provider Enumeration Date:
12/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OT6542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OT0065420 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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