Provider Demographics
NPI:1700624004
Name:CERULEAN KOI LLC
Entity type:Organization
Organization Name:CERULEAN KOI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-477-3756
Mailing Address - Street 1:110 W RANDOL MILL RD STE 243
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-4611
Mailing Address - Country:US
Mailing Address - Phone:682-477-3756
Mailing Address - Fax:469-833-4712
Practice Address - Street 1:110 W RANDOL MILL RD STE 243
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4611
Practice Address - Country:US
Practice Address - Phone:682-477-3756
Practice Address - Fax:469-833-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service