1902329147 NPI number — CRYSTAL HOSPICE CARE LLC

Table of content: (NPI 1902329147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902329147 NPI number — CRYSTAL HOSPICE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL HOSPICE CARE 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:
QUANTUM HEALTHCARE
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:
1902329147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14140 MIDWAY RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMERS BRANCH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-930-2386
Provider Business Mailing Address Fax Number:
469-722-3622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14110 DALLAS PKWY STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75254-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-941-9522
Provider Business Practice Location Address Fax Number:
972-546-4792
Provider Enumeration Date:
07/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ZACHARIAH
Authorized Official First Name:
BETSON
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
214-941-9522

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001030974 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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