Provider Demographics
NPI:1376080614
Name:CRYSTAL SERENITY HOUSE
Entity Type:Organization
Organization Name:CRYSTAL SERENITY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-709-8296
Mailing Address - Street 1:14241 FAUST AVE STE 200-B
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-3574
Mailing Address - Country:US
Mailing Address - Phone:888-609-6012
Mailing Address - Fax:313-736-3471
Practice Address - Street 1:14241 FAUST AVE STE 200-B
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-3574
Practice Address - Country:US
Practice Address - Phone:888-609-6012
Practice Address - Fax:313-736-3471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home