Provider Demographics
NPI:1417029885
Name:CRESTWOOD CONVALESCENT - PORT ANGELES LLC
Entity Type:Organization
Organization Name:CRESTWOOD CONVALESCENT - PORT ANGELES LLC
Other - Org Name:CRESTWOOD HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOV
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:1116 EAST LAURIDSEN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6640
Mailing Address - Country:US
Mailing Address - Phone:360-452-9206
Mailing Address - Fax:360-457-2935
Practice Address - Street 1:1116 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6640
Practice Address - Country:US
Practice Address - Phone:360-452-9206
Practice Address - Fax:360-457-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111688Medicaid
WA505185Medicare Oscar/Certification