MEDICARE: CRYSTAL BLUE SAPPHIRE HCS LLC

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	251S00000X	Community/Behavioral Health Agency	251C00000X	TX

General Provider Information

NPI Number	:	1477798932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL BLUE SAPPHIRE HCS LLC

Provider Business Mailing Address
First Line	:	14107 BRAYFORD PLACE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77014-2063
Country	:	US
Telephone Number	:	832-335-4346
Fax Number	:

Provider Business Practice Location Address
First Line	:	14107 BRAYFORD PLACE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77014-2063
Country	:	US
Telephone Number	:	832-335-4346
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MRS. DANYELL GRACE HALL
Credential	:
Telephone Number	:	832-335-4346

Provider Enumeration Date	:	12/11/2008
Last Update Date	:	12/30/2008

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