Provider Demographics
NPI:1467592618
Name:CRYSTAL OAKS LONG TERM CARE
Entity Type:Organization
Organization Name:CRYSTAL OAKS LONG TERM CARE
Other - Org Name:CRYSTAL OAKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:636-933-1897
Mailing Address - Street 1:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019-0680
Mailing Address - Country:US
Mailing Address - Phone:636-933-1818
Mailing Address - Fax:636-933-1894
Practice Address - Street 1:1500 CALVARY CHURCH RD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4125
Practice Address - Country:US
Practice Address - Phone:636-933-1818
Practice Address - Fax:636-933-1894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040114314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107808909Medicaid
MO26-5369Medicare Oscar/Certification