Provider Demographics
NPI:1124583349
Name:CRYSTAL WELLNESS CENTER INC
Entity Type:Organization
Organization Name:CRYSTAL WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-802-4695
Mailing Address - Street 1:116 GALLERY CIR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3341
Mailing Address - Country:US
Mailing Address - Phone:210-802-4695
Mailing Address - Fax:210-802-4698
Practice Address - Street 1:116 GALLERY CIR STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3341
Practice Address - Country:US
Practice Address - Phone:210-802-4695
Practice Address - Fax:210-802-4698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty