Provider Demographics
NPI:1164418554
Name:CRESTHAVEN HEALTH CARE CENTER LTD CO
Entity Type:Organization
Organization Name:CRESTHAVEN HEALTH CARE CENTER LTD CO
Other - Org Name:MAGNOLIA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-954-4114
Mailing Address - Street 1:2537 GOLDEN BEAR DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-2377
Mailing Address - Country:US
Mailing Address - Phone:214-954-4114
Mailing Address - Fax:214-871-3057
Practice Address - Street 1:4400 GULF AVE
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-3717
Practice Address - Country:US
Practice Address - Phone:409-962-5785
Practice Address - Fax:409-962-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114561314000000X
332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022622701Medicaid
TX000446604Medicaid
TX021439701Medicaid
TX455538Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TX021439701Medicaid