1215920939 NPI number — CRESTVIEW ACRES, INC

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 1215920939 NPI number — CRESTVIEW ACRES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTVIEW ACRES, 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:
1215920939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8350 HICKMAN RD
Provider Second Line Business Mailing Address:
SUITE 15
Provider Business Mailing Address City Name:
CLIVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50325-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-276-3656
Provider Business Mailing Address Fax Number:
515-276-4353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1485 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52302-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-377-4823
Provider Business Practice Location Address Fax Number:
319-377-4501
Provider Enumeration Date:
08/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VOYNA
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
515-276-3656

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0806398 , 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: 0806398 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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