Provider Demographics
NPI:1982291316
Name:CRISTAL PROVIDER SERVICES, LLC.
Entity Type:Organization
Organization Name:CRISTAL PROVIDER SERVICES, LLC.
Other - Org Name:CRISTAL PROVIDER SERVICES, LLC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-735-3341
Mailing Address - Street 1:1002 N AVASOLO ST
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-2811
Mailing Address - Country:US
Mailing Address - Phone:956-317-1009
Mailing Address - Fax:956-488-0525
Practice Address - Street 1:1002 N AVASOLO ST
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-2811
Practice Address - Country:US
Practice Address - Phone:956-317-1009
Practice Address - Fax:956-488-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty