1164418554 NPI number — CRESTHAVEN HEALTH CARE CENTER LTD CO

Table of content: (NPI 1164418554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164418554 NPI number — CRESTHAVEN HEALTH CARE CENTER LTD CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTHAVEN HEALTH CARE CENTER LTD CO
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:
1164418554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2537 GOLDEN BEAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75006-2377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-954-4114
Provider Business Mailing Address Fax Number:
214-871-3057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 GULF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROVES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77619-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-962-5785
Provider Business Practice Location Address Fax Number:
409-962-2944
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
UNDERHILL
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE
Authorized Official Telephone Number:
214-954-4114

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  114561 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 022622701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000446604 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021439701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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