=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538610530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL BEACH VENTURES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2016
-----------------------------------------------------
Last Update Date | 10/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 MARKET ST SUITE 101
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77550-1689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-974-4935
-----------------------------------------------------
Fax | 409-632-7980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 MARKET ST SUITE 101
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77550-1689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-974-4935
-----------------------------------------------------
Fax | 409-632-7980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MIKE WILLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-868-6112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 017585
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------