1104861038 NPI number — CRYSTAL CITY NURSING CENTER, INC.

Table of content: (NPI 1104861038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104861038 NPI number — CRYSTAL CITY NURSING CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CITY 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:
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:
1104861038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-925-4436
Provider Business Mailing Address Fax Number:
610-925-4351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1785 S HAYES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22202-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-920-5700
Provider Business Practice Location Address Fax Number:
703-979-8190
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DROPESKEY
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE MANAGER
Authorized Official Telephone Number:
610-925-4231

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2655 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 030909900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02PV . This is a "CAREFIRST-PROV/INQ#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 241381 . This is a "UNITED - MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: H18 . This is a "CAREFIRST - IND/PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 47579 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: H18 . This is a "CAREFIRST BLUECHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 147180 . This is a "SOUTHERN HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100077 . This is a "UNITED - AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004951140 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0082366 . This is a "AETNA-HMO" identifier . This identifiers is of the category "OTHER".




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