Provider Demographics
NPI:1811424708
Name:KRYSTAL FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:KRYSTAL FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:OMENUKOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:972-576-7399
Mailing Address - Street 1:1675 REPUBLIC PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6902
Mailing Address - Country:US
Mailing Address - Phone:972-576-7399
Mailing Address - Fax:972-476-0006
Practice Address - Street 1:1675 REPUBLIC PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-576-7399
Practice Address - Fax:972-476-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty