Provider Demographics
NPI:1285160853
Name:CRYO BODY SHAPE
Entity type:Organization
Organization Name:CRYO BODY SHAPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSE
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE RN
Authorized Official - Phone:281-684-5412
Mailing Address - Street 1:7219 GLEN ELLEN BAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1757
Mailing Address - Country:US
Mailing Address - Phone:281-684-5412
Mailing Address - Fax:
Practice Address - Street 1:7219 GLEN ELLEN BAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1757
Practice Address - Country:US
Practice Address - Phone:281-684-5412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX637553261QP2000X, 261QP3300X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX261Q0000XMedicaid
TX224X000000XMedicaid
TX261QP2000XMedicaid