Provider Demographics
NPI:1255690079
Name:COUNTRY CREST, LLC
Entity Type:Organization
Organization Name:COUNTRY CREST, LLC
Other - Org Name:COUNTRY CREST POST ACUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-309-0022
Mailing Address - Street 1:530 N. PUENTE STREET
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821
Mailing Address - Country:US
Mailing Address - Phone:530-533-7857
Mailing Address - Fax:530-533-7887
Practice Address - Street 1:50 CONCORDIA LANE
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-533-7857
Practice Address - Fax:530-533-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
CA230000351314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
555802Medicare Oscar/Certification
CA555802Medicare Oscar/Certification