Provider Demographics
NPI:1407931009
Name:JEANNETTE R BRANTLEY
Entity Type:Organization
Organization Name:JEANNETTE R BRANTLEY
Other - Org Name:CRYSTAL MANOR ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-875-9525
Mailing Address - Street 1:6016 W LAKE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RIESEL
Mailing Address - State:TX
Mailing Address - Zip Code:76682-3504
Mailing Address - Country:US
Mailing Address - Phone:254-875-9525
Mailing Address - Fax:254-875-9526
Practice Address - Street 1:6016 W LAKE CREEK RD
Practice Address - Street 2:
Practice Address - City:RIESEL
Practice Address - State:TX
Practice Address - Zip Code:76682-3504
Practice Address - Country:US
Practice Address - Phone:254-875-9525
Practice Address - Fax:254-875-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000598310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility