Provider Demographics
NPI:1043972649
Name:CRESTONE WELLNESS LLC
Entity Type:Organization
Organization Name:CRESTONE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-319-8510
Mailing Address - Street 1:301 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1848
Mailing Address - Country:US
Mailing Address - Phone:737-327-9083
Mailing Address - Fax:830-460-5261
Practice Address - Street 1:301 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1848
Practice Address - Country:US
Practice Address - Phone:737-327-9083
Practice Address - Fax:830-460-5261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility