MEDICARE: CRYSTAL GALE WOODS CPT

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	374700000X	Technician	L5G6A5H7	TX

General Provider Information

NPI Number	:	1568125979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL GALE WOODS CPT

Provider Business Mailing Address
First Line	:	3321 BLUESTEM CIR
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-5901
Country	:	US
Telephone Number	:	979-200-8031
Fax Number	:

Provider Business Practice Location Address
First Line	:	3321 BLUESTEM CIR
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-5901
Country	:	US
Telephone Number	:	979-200-8031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2021
Last Update Date	:	10/21/2021

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