Provider Demographics
NPI:1154643328
Name:CRESCENT HOME HEALTH AGENCY, LLC
Entity Type:Organization
Organization Name:CRESCENT HOME HEALTH AGENCY, LLC
Other - Org Name:NA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIKANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAJWA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-741-3800
Mailing Address - Street 1:7 PARK PL STE B
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2916
Mailing Address - Country:US
Mailing Address - Phone:618-277-0939
Mailing Address - Fax:618-277-0949
Practice Address - Street 1:7 PARK PL STE B
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-277-0939
Practice Address - Fax:618-277-0949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011293251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-8190OtherMEDICARE CCN (PTAN)
IL14-8190OtherMEDICARE CCN (PTAN)