1710940358 NPI number — CREST HAVEN CARE CENTER, LLC

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 1710940358 NPI number — CREST HAVEN CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREST HAVEN CARE CENTER, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1710940358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11523 PALMBRUSH TRL
Provider Second Line Business Mailing Address:
SUITE 331
Provider Business Mailing Address City Name:
LAKEWOOD RANCH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34202-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-758-4745
Provider Business Mailing Address Fax Number:
888-391-2373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E HOWARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50801-2723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-782-5012
Provider Business Practice Location Address Fax Number:
641-782-5309
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENCH
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
941-758-4745

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  880066 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0800080 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0800425 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0236984 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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