1023010071 NPI number — CRESTWOOD NURSING CENTER INC

Table of content: (NPI 1023010071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023010071 NPI number — CRESTWOOD NURSING CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTWOOD NURSING CENTER INC
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:
PUTNAM COUNCIL ON AGING INC
Provider Other Organization Name Type Code:
4
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:
1023010071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
995 CANTON ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30075-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
709-934-0000
Provider Business Mailing Address Fax Number:
386-325-1531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32177-4147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-328-1472
Provider Business Practice Location Address Fax Number:
386-325-1531
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAGAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-993-4000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 031227400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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