MEDICARE: CRYSTAL EMS INC

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	3416L0300X	Land Ambulance	1000762	TX

General Provider Information

NPI Number	:	1891065652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL EMS INC

Provider Business Mailing Address
First Line	:	3950 ASHBURNHAM DR
Second Line	:	30
City	:	HOUSTON
State	:	TX
Zip	:	77082-5921
Country	:	US
Telephone Number	:	832-790-1618
Fax Number	:	832-365-6144

Provider Business Practice Location Address
First Line	:	3950 ASHBURNHAM DR
Second Line	:	30
City	:	HOUSTON
State	:	TX
Zip	:	77082-5921
Country	:	US
Telephone Number	:	832-790-1618
Fax Number	:	832-365-6144

Authorized Official
Title or Position	:	OWNER
Name	:	OLUGBENGA A BAKARE
Credential	:
Telephone Number	:	832-790-1618

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	01/10/2012

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