1114948825 NPI number — CRYSTAL BEACH MEDICAL CLINIC LLC

Table of content: SUKAINA RIZVI MD (NPI 1003438169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114948825 NPI number — CRYSTAL BEACH MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL BEACH MEDICAL CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114948825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL BEACH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77650-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-454-2543
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 S. EAST RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL BEACH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77650-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-454-2543
Provider Business Practice Location Address Fax Number:
866-521-5608
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
LEVER
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
409-454-2543

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 182389002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 182389001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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