Provider Demographics
NPI:1437130747
Name:FLO-GP LEASING CO., LLC
Entity Type:Organization
Organization Name:FLO-GP LEASING CO., LLC
Other - Org Name:CRYSTAL CREEK HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-489-7100
Mailing Address - Street 1:4700 ASHWOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2465
Mailing Address - Country:US
Mailing Address - Phone:513-489-7100
Mailing Address - Fax:513-530-1359
Practice Address - Street 1:250 S NEW FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-6716
Practice Address - Country:US
Practice Address - Phone:314-838-2211
Practice Address - Fax:314-838-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030945314000000X
320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107807703Medicaid
MO265607Medicare Oscar/Certification
MO6146610001Medicare NSC