Provider Demographics
NPI:1609550219
Name:MYSTI BLU LLC
Entity Type:Organization
Organization Name:MYSTI BLU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNESTINE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:972-522-9799
Mailing Address - Street 1:3333 PRESTON ROAD
Mailing Address - Street 2:#300
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:972-522-9799
Mailing Address - Fax:
Practice Address - Street 1:2459 E. HEBRON PARKWAY
Practice Address - Street 2:#130
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010
Practice Address - Country:US
Practice Address - Phone:972-522-9799
Practice Address - Fax:469-546-9723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No251F00000XAgenciesHome InfusionGroup - Single Specialty