Provider Demographics
NPI:1598767162
Name:CRYSTAL CARE HOME HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:CRYSTAL CARE HOME HEALTH SERVICES, INC.
Other - Org Name:CRYSTAL CARE HOME HEALTH SERVICES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEYNA
Authorized Official - Middle Name:N
Authorized Official - Last Name:OMENUKOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:972-203-2121
Mailing Address - Street 1:1675 REPUBLIC PARKWAY
Mailing Address - Street 2:#200
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:972-203-2121
Mailing Address - Fax:972-203-8384
Practice Address - Street 1:1675 REPUBLIC PARKWAY
Practice Address - Street 2:#200
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-203-2121
Practice Address - Fax:972-203-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX006494251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000038800Medicaid
TX0008674000Medicaid
TX459369Medicare Oscar/Certification