Provider Demographics
NPI:1205822517
Name:CRESTWOOD NURSING AND CONVALESCENT HOME INC
Entity Type:Organization
Organization Name:CRESTWOOD NURSING AND CONVALESCENT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MINASSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-245-1574
Mailing Address - Street 1:568 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-1734
Mailing Address - Country:US
Mailing Address - Phone:401-245-1574
Mailing Address - Fax:401-247-0211
Practice Address - Street 1:568 CHILD ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-1734
Practice Address - Country:US
Practice Address - Phone:401-245-1574
Practice Address - Fax:401-247-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI628314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI628Medicaid
RI628Medicaid