Provider Demographics
NPI:1003632522
Name:MYSTI BLU MANAGEMENT GROUP, LLC
Entity type:Organization
Organization Name:MYSTI BLU MANAGEMENT GROUP, 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-C
Authorized Official - Phone:310-756-4829
Mailing Address - Street 1:2459 E HEBRON PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4477
Mailing Address - Country:US
Mailing Address - Phone:972-522-9799
Mailing Address - Fax:469-546-9723
Practice Address - Street 1:2459 E HEBRON PKWY STE 130
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4477
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:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251F00000XAgenciesHome InfusionGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty