Provider Demographics
NPI:1639383649
Name:FIRST CRYSTALCARE, INC.
Entity type:Organization
Organization Name:FIRST CRYSTALCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KEYNA
Authorized Official - Middle Name:NKEMJIKA
Authorized Official - Last Name:OMENUKOR
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:972-279-0682
Mailing Address - Street 1:1675 REPUBLIC PARKWAY, SUITE 200C
Mailing Address - Street 2:1675 REPUBLIC PARKWAY, SUITE 200C
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6902
Mailing Address - Country:US
Mailing Address - Phone:972-279-0682
Mailing Address - Fax:972-279-0689
Practice Address - Street 1:1675 REPUBLIC PARKWAY, SUITE 200C
Practice Address - Street 2:1675 REPUBLIC PARKWAY, SUITE 200C
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-279-0682
Practice Address - Fax:972-279-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001026230Medicaid