Provider Demographics
NPI:1780934273
Name:KRISTINE LICENSED SURGICAL ASSISTANT
Entity type:Organization
Organization Name:KRISTINE LICENSED SURGICAL ASSISTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-227-2457
Mailing Address - Street 1:515 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:DOUBLE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3028
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:972-463-7247
Practice Address - Street 1:515 KINGS RD
Practice Address - Street 2:
Practice Address - City:DOUBLE OAK
Practice Address - State:TX
Practice Address - Zip Code:75077-3028
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:972-463-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00357163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty