Provider Demographics
NPI:1437163243
Name:CRESTLINE FACILTY OPERATIONS, LLC
Entity Type:Organization
Organization Name:CRESTLINE FACILTY OPERATIONS, LLC
Other - Org Name:CRESTLINE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:800 CONCOURSE PKWY S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6148
Mailing Address - Country:US
Mailing Address - Phone:407-571-1550
Mailing Address - Fax:407-571-1599
Practice Address - Street 1:327 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-1434
Practice Address - Country:US
Practice Address - Phone:419-683-3255
Practice Address - Fax:419-683-4118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONSULATE HEALTH CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2709804Medicaid
OH2709804Medicaid
36-6002Medicare PIN