Healthcare Provider Details

I. General information

NPI: 1104763705
Provider Name (Legal Business Name): CRYSTOL MARIE HILL INOCENCIO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 N PEACH ST
ORE CITY TX
75683-2312
US

IV. Provider business mailing address

704 N PEACH ST
ORE CITY TX
75683-2312
US

V. Phone/Fax

Practice location:
  • Phone: 956-645-1274
  • Fax:
Mailing address:
  • Phone: 956-645-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2064230
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: