Healthcare Provider Details

I. General information

NPI: 1295880219
Provider Name (Legal Business Name): CRYSTAL OUTPATIENT SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10565 KATY FREEWAY SUITE 100
HOUSTON TX
77024
US

IV. Provider business mailing address

10565 KATY FREEWAY SUITE 100
HOUSTON TX
77024
US

V. Phone/Fax

Practice location:
  • Phone: 713-467-0146
  • Fax: 713-467-9413
Mailing address:
  • Phone: 713-467-0146
  • Fax: 713-467-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberH2191
License Number StateTX

VIII. Authorized Official

Name: MR. BRET WAYNE BROKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 713-467-0146