1083882682 NPI number — CRESTWOOD HEALTH CARE CENTER, L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083882682 NPI number — CRESTWOOD HEALTH CARE CENTER, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTWOOD HEALTH CARE CENTER, L.L.C.
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:
CRESTWOOD HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1083882682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1869 CRAIG PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-3800
Provider Business Mailing Address Fax Number:
314-543-3880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11400 MEHL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORISSANT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63033-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-741-3525
Provider Business Practice Location Address Fax Number:
314-741-3721
Provider Enumeration Date:
02/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUNDOO
Authorized Official First Name:
ASHWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE
Authorized Official Telephone Number:
314-543-3800

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: 038173 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102504701 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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