Healthcare Provider Details

I. General information

NPI: 1417867631
Provider Name (Legal Business Name): CRESTLINE ONE SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MOCKINGBIRD LN
DAYTON TX
77535-9215
US

IV. Provider business mailing address

9659 N SAM HOUSTON PKWY E STE 150
HUMBLE TX
77396-1290
US

V. Phone/Fax

Practice location:
  • Phone: 832-655-8383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHAHEENA KHAN
Title or Position: OWNER
Credential:
Phone: 832-655-8383