1194743088 NPI number — CRESTWOOD BEHAVIORAL HEALTH,INC.

Table of content: (NPI 1194743088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194743088 NPI number — CRESTWOOD BEHAVIORAL HEALTH,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTWOOD BEHAVIORAL HEALTH,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:
CRESTWOOD WELLNESS AND RECOVERY 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:
1194743088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7590 SHORELINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95219-5455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-955-2328
Provider Business Mailing Address Fax Number:
209-952-5314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3062 CHURN CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96002-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-221-0976
Provider Business Practice Location Address Fax Number:
530-223-3923
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
209-955-2328

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: LTC90053G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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