MEDICARE: FIRST CRYSTALCARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant
2	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639383649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST CRYSTALCARE, INC.

Provider Business Mailing Address
First Line	:	1675 REPUBLIC PARKWAY, SUITE 200C
Second Line	:	1675 REPUBLIC PARKWAY, SUITE 200C
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-279-0682
Fax Number	:	972-279-0689

Provider Business Practice Location Address
First Line	:	1675 REPUBLIC PARKWAY, SUITE 200C
Second Line	:	1675 REPUBLIC PARKWAY, SUITE 200C
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-279-0682
Fax Number	:	972-279-0689

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. KEYNA NKEMJIKA OMENUKOR
Credential	:	APRN-CNP
Telephone Number	:	972-279-0682

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	10/04/2024

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Directions to “FIRST CRYSTALCARE, INC. ” Practice Location

Language	Start Address	Practice Location

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