Provider Demographics
NPI:1073500831
Name:SHADESCREST HEALTH CARE CENTER
Entity Type:Organization
Organization Name:SHADESCREST HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-384-9086
Mailing Address - Street 1:331 25TH ST W
Mailing Address - Street 2:P.O. BOX 1012
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-5828
Mailing Address - Country:US
Mailing Address - Phone:205-384-9086
Mailing Address - Fax:205-387-2225
Practice Address - Street 1:331 25TH ST W
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5828
Practice Address - Country:US
Practice Address - Phone:205-384-9086
Practice Address - Fax:205-387-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10671314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4754101SMedicaid
AL015114Medicare ID - Type UnspecifiedPROVIDER NUMBER