Provider Demographics
NPI:1063256246
Name:CRESTCARE MEDICAL SUPPLY
Entity type:Organization
Organization Name:CRESTCARE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEUGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-276-9739
Mailing Address - Street 1:9304 FOREST LN STE S236
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-6238
Mailing Address - Country:US
Mailing Address - Phone:469-290-4700
Mailing Address - Fax:
Practice Address - Street 1:9304 FOREST LN STE S236
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6238
Practice Address - Country:US
Practice Address - Phone:469-290-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies