Provider Demographics
NPI:1295880219
Name:CRYSTAL OUTPATIENT SURGERY CENTER
Entity type:Organization
Organization Name:CRYSTAL OUTPATIENT SURGERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BROKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-467-0146
Mailing Address - Street 1:10565 KATY FREEWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024
Mailing Address - Country:US
Mailing Address - Phone:713-467-0146
Mailing Address - Fax:713-467-9413
Practice Address - Street 1:10565 KATY FREEWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:713-467-0146
Practice Address - Fax:713-467-9413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2191208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E02209Medicare UPIN